Citation Nr: 1310366 Decision Date: 03/27/13 Archive Date: 04/09/13 DOCKET NO. 10-23 910 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an evaluation in excess of 20 percent for surgical excision of osteoma of the right hip (hereinafter right hip disability). 2. Entitlement to an initial evaluation in excess of 10 percent for right lateral femoral cuteaneous nerve neuropathy associated with the right hip disability. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his neighbor, J.E. ATTORNEY FOR THE BOARD M. Peters, Associate Counsel INTRODUCTION The Veteran had active duty service from January 1943 to August 1946, and from March 1951 to May 1952. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which denied an increased evaluation for the Veteran's right hip disability and entitlement to TDIU. The Veteran timely appealed that decision. The Veteran and his neighbor, J.E., testified at a Board hearing in December 2010; a transcript of that hearing is associated with the claims file. This case was last before the Board in January 2011, when it was remanded for further development. That development having been completed, the case has been returned to the Board for further appellate review at this time. During the pendency of the prior remand, the Veteran was awarded a separate 10 percent evaluation for his right leg neuropathy associated with his right hip disability in a December 2012 rating decision. As the right leg neuropathy has been associated with the right hip disability on appeal, the Board will address that issue in this decision along with the right hip disability. Finally, the Board notes that the Veteran filed a claim of service connection for posttraumatic stress disorder (PTSD). In a May 2011 rating decision, the RO deferred that claim for compensation. In a March 2012 rating decision, it appears that the RO denied eligibility for treatment for psychosis; as of this time, it does not appear that the RO has addressed the Veteran's claim of service connection for PTSD. Accordingly, the issue of service connection for PTSD has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran's right hip flexion is not limited to 20 degrees throughout the appeal period; nor is there any evidence of right hip ankylosis, a flail joint, limited extension to 5 degrees, limited abduction with motion lost beyond 10 degrees, limited adduction such that he is unable to cross his legs, limited rotation such that he cannot toe-out his right leg more than 15 degrees, or fracture of the anatomical or surgical neck or shaft, or nonunion or malunion, of the Veteran's femur throughout the appeal period. 2. The evidence of record more closely approximates mild right leg neuropathy throughout the appeal period. 3. The Veteran's right hip scar is not tender, and is otherwise not compensable. 4. By resolving doubt in favor of the Veteran, the evidence of record demonstrates that the Veteran's service-connected disabilities, including his right hip disability and bilateral hearing loss, preclude him from obtaining and maintaining substantially gainful employment commensurate with his level of education, training, and past work experience. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for the Veteran's right hip disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a, 4.118, Diagnostic Codes 5015, 5250-55, 7800-04 (2012). 2. The criteria for an initial evaluation in excess of 10 percent for right leg neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8599-8526 (2012). 3. The criteria for a separate 10 percent rating for a tender scar of the right hip have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7804 (2012). 4. Resolving doubt in favor of the Veteran, the criteria establishing entitlement to TDIU have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In a claim for increase, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009). The Veteran's right leg neuropathy claim arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). With regards to the Veteran's increased evaluation claim for his right hip disability, the Veteran was sent a letter in July 2008 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at a December 2010 hearing before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims herein decided. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2012); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2012); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2012); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2012). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the claimant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider a veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Id.; Powell v. West, 13 Vet. App. 31, 35 (1999). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2012); see also 38 C.F.R. § 4.45 (2012). On appeal, the Veteran has averred that he should be assigned a higher evaluation for his right hip disability because the pain he has is "severe," "unbearable," and limits his ability to walk and stand. The Veteran testified in his December 2010 hearing that he used a cane to ambulate and that he fell constantly due to his disability. He indicated that he was limited in his ability to stand, walk, drive and do other activities of daily living because of his right hip disability. The Veteran's neighbor, J.E., testified that he has to visit at least 2 to 3 times a week to help the him with chores, pick the Veteran up after he fell, or to take him to run errands. The Veteran testified further that he does not get any formal treatment for his right hip disability from VA or private physicians, instead treating the disability himself. He did indicate that he gets Percocet from VA for his pain. Review of the Veteran's VA and private records corroborates that the Veteran does not seek treatment for his right leg disability or neuropathy with either VA or private physicians. The VA treatment records document that the Veteran has complaints of right hip pain and that he is given Percocet for his pain, but no actual treatment or examination of his right hip is shown in those records. The Veteran filed his claim for increased evaluation of his right hip disability in March 2008. In July 2008, he underwent a VA examination of his right hip. At that time he reported that he had a right pelvis surgery in the 1950s during service to remove an osteoma of the right iliac bone; since that time, his pain has progressively worsened. He noted that he had radiating pain down his right leg off and on for the last 20 years. His pain is relieved by rest and pain medication, before it recurs again. The Veteran's pain is 5 to 9 out of 10 and constant. He reported weakness and stiffness of his right hip, without swelling, redness or heat. There was no locking of the right hip, but he reported occasional giving way. He reported taking 2 to 4 Percocets a day. His pain has flare-ups spontaneously without any precipitating factors; flare-ups occur once a week and are relieved by medication and applying heat to the right hip. The Veteran uses a cane and a walker. He also reported that his condition affected his walking, limiting him to less than one block. The Veteran stated that he was mostly confined to his home, unless it was for medical reasons. On examination, the Veteran was able to ambulate from the chair to the examining table without external support, though he limped favoring his right lower extremity. The Veteran had a normal heel-strike and toe-off gait; no muscular weakness of the lower extremities was noted. The Veteran's right hip had a well-healed scar over the right iliac crest extending from the mid-anterior portion iliac crest to the anterior and superior iliac spine. It was tender to palpation at the lower pole of the wound but was otherwise painless. There was no evidence of any inflammatory processes at the wound site. The Veteran's patellar reflexes were 1+ and minus Achilles reflexes bilaterally. Straight leg raising was negative bilaterally. He had areas of decreased sensation in portions of his bilateral lower extremities. The Veteran's right hip had forward flexion to 90 degrees, extension to 0 degrees, adduction to 15 degrees, abduction to 35 degrees, external rotation to 45 degrees, and internal rotation to 15 degrees. X-rays from July 2008 demonstrated evidence of partial removal of the right iliac bone, with some sclerotic lesions in the neck of the right iliac bone. The examiner noted that repetitive motions of the Veteran's right hip did not affect his range of motion, pain, fatigability, weakness or endurance; he further stated that he could not opine, without speculation, as to any decrease of the Veteran's right hip range of motion during flare up. In February 2011, the Veteran underwent a VA examination of his neuropathy in his right leg. He reported that in the past year he had worsening numbness and tingling to his right leg. The Veteran treated this condition with Percocet. It was noted that he required a cane for ambulation. He reported paresthesias, dysesthesias and pain of the right leg, including numbness and tingling. On examination, the Veteran's LFCN, sural nerve was shown to be affected; the right lower extremity demonstrated normal vibration and position sense, but decreased pain/pinprick and light touch of the lateral aspect of the leg. He did not have dysesthesias. The Veteran's muscle strength in his hip and knee flexion and extension, ankle dorsiflexion and plantar flexion, and great toe extension were all 5 out of 5. His muscle tone was normal and there was no evidence of muscle atrophy. He had an unsteady gait that required a cane for ambulation. There was no imbalance or tremor, evidence of fasciculations, or other evidence that the function of the joint was affected by the nerve disorder. The Veteran was ordered to have an electromyographic study performed, but he failed to report for that examination. The Veteran was diagnosed as having right leg neuropathy associated with his right hip disability resulting from his surgery. The Veteran had nerve dysfunction but did not have paralysis; however, he had neuritis and neuralgia. The Veteran's neuropathy did not have any effect on his occupation and there was mild effect on his ability to do his usual daily activities, including chores, and a moderate effect on his ability to participate in sports or exercise. Finally, the Veteran underwent a VA examination of his right lower extremity in October 2012. The Board notes that the Veteran's right neuropathy was not examined at this time. The Veteran reported having continued pain, numbness and tingling of his right lower extremity. The Veteran's right hip had flexion to 90 degrees where painful motion began. The Veteran's right hip extension was greater than 5 degrees, with painful motion beginning greater than 5 degrees. The Veteran did not have abduction lost beyond 10 degrees, adduction limited such that he could not cross his legs, or rotation limited such that he could not toe-out more than 15 degrees. The Veteran was able to perform repetitive testing without any change to the range of motion noted above. The examiner noted that the Veteran had less movement than normal, weakened movement, pain on movement and disturbance of locomotion in his right lower extremity as his functional impairments associated with his right hip disability. The Veteran had localized pain/tenderness on palpation on his right hip. The Veteran had normal muscle strength in right hip flexion, extension, and abduction; there was no ankylosis of the right hip noted on examination. Moreover, the examination noted that there was no malunion, nonunion, leg length discrepancy or false flail joint of the right hip on examination. Although the examiner noted that the Veteran had a total hip replacement, it appears that such was erroneously checked-the Veteran has not alleged, nor is there any evidence of record that he had a total right hip replacement surgery at anytime during his life. The examiner noted that the Veteran had decreased sensation LFCN and sural nerve distribution. Finally, the examiner noted that the Veteran had a right hip scar due to his surgery in service. The examiner noted that such scar was not painful or unstable on examination. He noted that the scar was linear and 11 cm in length. The examiner noted that the scar would not affect the Veteran's ability to work and that he would be able to maintain sedentary employment. On the basis of the foregoing evidence, the Board finds that a higher evaluation for the right hip disability is not warranted. Currently, the Veteran is assigned a 20 percent disability rating under Diagnostic Code 5015-5252. Diagnostic Code 5015 directs to rate the Veteran on the basis of arthritis and limitation of motion of the affect body part, except in the cases of gout. See 38 C.F.R. § 4.71a, Diagnostic Code 5015 (2012). Accordingly, the relevant Diagnostic Codes potentially applicable in this case are of the Hip and Thigh, Diagnostic Codes 5250 through 5255. On the basis of the evidence above, the Board notes that there is no ankylosis of the right hip demonstrated at any time throughout the appeal period, therefore Diagnostic Code 5250 is not applicable. See 38 C.F.R. § 4.71a, Diagnostic Code 5250 (2012). Likewise, there was no evidence of a flail joint, fracture of the anatomical or surgical neck or shaft of, or nonunion or malunion of the Veteran's femur throughout the appeal period; thus, Diagnostic Codes 5254 and 5255 are equally not applicable in this case. See 38 C.F.R. § 4.71a, Diagnostic Codes 5254, 5255 (2012). This leaves the Board with Diagnostic Codes 5251, 5252, and 5253 to consider. First, Diagnostic Code 5252 provides that a 10 percent evaluation is warranted for hip flexion limited to 45 degrees; a 20 percent evaluation for flexion limited to 30 degrees; a 30 percent evaluation for flexion limited to 20 degrees; and, a 40 percent evaluation for hip flexion limited to 10 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5252 (2012). Throughout the appeal period, the Veteran's right hip flexion is not shown to be limited to 20 degrees or less. The Board acknowledges the Veteran's complaints of "severe and unbearable pain" as well as his limitations in walking, standing, driving, and other activities of daily living. The Board, however, must find that a higher evaluation than the currently assigned 20 percent evaluation is not for application in this case. The Board has additionally considered whether the Veteran's right hip disability warrants separate evaluations under Diagnostic Codes 5251 and 5253. See 38 C.F.R. § 4.14 (2012); see also Estaban v. Brown, 6 Vet. App. 259 (1994) (in cases where separate and distinct manifestations have arisen from the same injury, separate disability ratings may be assigned where none of the symptomatology of the conditions overlaps). In this case, a separate 10 percent evaluation would be warranted if the Veteran's extension of his right hip was limited to 5 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5251 (2012). As the above evidence demonstrates, the Veteran's extension was not limited to 5 degrees of extension throughout the appeal period. Accordingly, an evaluation under Diagnostic Code 5251 is not for application in this case. See 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5251. Likewise, a separate 10 percent evaluation would be warranted where the Veteran's hip had adduction limited such that he could not cross his legs or limited rotation such that he cannot toe-out his affected leg more than 15 degrees. A 20 percent evaluation would be warranted if there was a limitation of abduction of the Veteran's hip with motion lost beyond 10 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5253 (2012). As the above evidence demonstrates, the Veteran's adduction, abduction and rotation of his right hip are not limited such as to warrant a separate evaluation under Diagnostic Code 5253. The Veteran is shown to be able to cross his legs in the most recent VA examination, and his rotation and abduction demonstrated throughout the appeal period are consistently more than 15 and 10 degrees, respectively. Accordingly, a separate evaluation under Diagnostic Code 5253 is not for application in this case. See 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5253. Accordingly, the Board must deny the Veteran's increased evaluation claim for his right hip disability. See 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5015, 5251-53. Turning to the Veteran's right leg neuropathy, the Board notes that the Veteran was assigned a 10 percent evaluation for that disability under Diagnostic Code 8599-8526, effective December 9, 2010. The Board finds that an evaluation in excess of 10 percent based on the evidence since December 9, 2008 is not warranted. Under Diagnostic Code 8526, a 10 percent evaluation is warranted for mild incomplete paralysis of the anterior crucal nerve (femoral); a 20 percent is warranted for moderate incomplete paralysis; a 30 percent evaluation is warranted for severe incomplete paralysis; and, a 40 percent evaluation is warranted for complete paralysis, with paralysis of the quadriceps extensor muscles. See 38 C.F.R. § 4.124a, Diagnostic Code 8526 (2012). Based on the evidence, particularly the February 2011 VA examination, the Board finds that a higher evaluation is not warranted because the Veteran's symptomatology does not more closely approximate moderate symptomatology in this case. The Veteran is shown to have decreased pain/pinprick and light touch sensation in the lateral aspect of his right lower extremity throughout the appeal period. The Veteran's muscle strength and reflexes throughout the appeal period, as well as his muscle tone, is shown to be normal. Although the February 2011 examiner reserved opining further on the severity of the Veteran's neuropathy until an electromyography had been obtained, the Veteran failed to report for that test. Such test may have demonstrated more significant pathology, but unfortunately, the results were never obtained because the Veteran never reported for that examination. The Board does not find that it is necessary to remand for another VA examination, as the Veteran has not provided any good cause for failing to appear for that electromyography. The Board has evaluated the evidence throughout the record, including the Veteran's lay evidence of numbness and tingling radiating down his right lower extremity. See Layno v. Brown, 6 Vet. App. 465 (1994). The Board, however, finds that the objective evidence is more probative in this case and more closely approximates to a finding of mild symptomatology, rather than moderate symptomatology. Accordingly, the Board finds that an initial evaluation in excess of 10 percent for the Veteran's right leg neuropathy is not warranted on the evidence of record in this case. See 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8526. Finally, with respect to the Veteran's noted right hip surgical scar, the Board finds that a separate 10 percent evaluation for that residual is not warranted at this time. The Board has specifically contemplated whether a separate evaluation for a residual scar is warranted in this case. See Estaban v. Brown, 6 Vet. App. 259 (1994) (in cases where separate and distinct manifestations have arisen from the same injury, separate disability ratings may be assigned where none of the symptomatology of the conditions overlaps). In this case, the Veteran's right hip scar is not of the head, face and neck. Therefore Diagnostic Code 7800 is not applicable. See 38 C.F.R. § 4.118, Diagnostic Code 7800 (2012). The Veteran's scar is shown to be linear, 11 cm in length, well-healed, and stable throughout the appeal period. Therefore, the Veteran does not meet the criteria necessary for a compensable evaluation under Diagnostic Codes 7801 or 7802 because the area associated with the Veteran's right hip scar does not rise to the level necessary for compensation. See 38 C.F.R. § 4.118, Diagnostic Code 7801, 7802 (2012). Finally, the Board notes that Diagnostic Code 7804 would compensable the Veteran's single right hip scar if such was painful. See 38 C.F.R. § 4.118, Diagnostic Code 7804 (2012). The Board, however, finds that the evidence of record does not support a finding that the Veteran's right hip scar is painful. The Board notes that the Veteran's right hip was tender on palpation in July 2008, but it does not note whether the Veteran's scar specifically was tender or painful; the examination did not delineate between the two and noted only that it was tender on palpation at the lower pole but was otherwise painless. In the October 2012 examination, that examiner specifically addressed the issue of whether the scar was painful and noted that the scar was not painful. Moreover, the Veteran's lay evidence of record does not include any complaints of his scar being painful during the appeal period. The Veteran specifically complains of pain, but the Board has factored those complaints of pain into the evaluation of his right hip disability itself in this case. As there is no direct lay evidence of his right hip scar being painful, the Board must find that the October 2012 examiner's examination findings that the scar is not painful on examination to be the most probative evidence in this case. Such evidence is also the most probative evidence as to the Veteran's scar symptomatology throughout the entire appeal period, which is that the Veteran's right hip scar was generally painless. Accordingly, the Board finds that a separate evaluation for a right hip scar is not warranted in this case because the scar does not warrant a compensable evaluation under the Rating Schedule at this time. See 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7804. The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2011). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluation is adequate. An evaluation in excess of that assigned is provided for certain manifestations of the service-connected right hip disability and right leg neuropathy, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disorders. As the rating schedule is adequate to evaluate the disability, referral for extraschedular consideration is not in order. Finally, the Board finds that TDIU is warranted on the evidence of record at this time. VA will award a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2012). If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341 (2012). In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability, and to the effects of combinations of disability. 38 C.F.R. § 4.15 (2012). A TDIU for compensation purposes may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more service-connected 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 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the above purpose of one 60 percent disability or one 40 percent disability, disabilities resulting from a common etiology or a single accident will be considered as one disability. 38 C.F.R. § 4.16(a)(1). Initially, the Board finds that the Veteran meets the schedular criteria for consideration for TDIU under 38 C.F.R. § 4.16(a). Specifically, the Veteran's bilateral hearing loss has been evaluated as 60 percent disabling and he has a 70 percent combined disability evaluation since December 9, 2010. Accordingly, the Board finds that the Veteran meets the schedular criteria for TDIU under 38 C.F.R. § 4.16(a). In determining whether an appellant is entitled to a TDIU, neither the appellant's nonservice-connected disabilities nor advancing age be considered. In this case, the Veteran filed an application for TDIU in April 2008, at which time he noted that he had been retired since 1990. He noted that he last worked as a teacher and that he had a bachelors and a masters degree. He listed his hearing loss, stroke and prostate cancer as reasons for his inability to work. The Board notes that in the March 2011 VA audiologic examination, the Veteran's hearing was shown to have "significant effects" on his occupational functioning, including "[d]iffculty hearing and understanding in all listening situations." In the October 2012 VA examination of his right hip disability, the Veteran was noted as being able to maintain sedentary employment. On the basis of the above, the Board finds that TDIU is warranted in this case. The Board acknowledges the Veteran's statements that he is unable to work due to his stroke and prostate cancer, but note that those conditions are not service-connected. The Board therefore cannot take those conditions into account as to whether the Veteran is unemployable or not. The Board notes that the Veteran's right hip disability restricts his employability to merely sedentary employment, which may or may not be prohibitive in the Veteran's last noted profession as a teacher. Sedentary work is additionally within the realm of educational and work experience for the Veteran as a teacher. The Board, however, notes that the Veteran's hearing loss would have "significant effects" on his ability to maintain employment due to his "difficulty hearing and understanding in all listening situations." The Board notes that a majority of the Veteran's last profession as a teacher would be listening to, conversing with, and interacting with his students. The fact that the Veteran would be both limited to having to sit in a classroom, rather than stand, and would have significant difficulty interacting with his students are major and significant factors weighing heavily in favor of finding that is not able to obtain and maintain substantially gainful employment as a result of his service-connected disabilities in this case. Accordingly, by resolving doubt in favor of the Veteran, the Board finds that entitlement to TDIU is warranted at this time on the basis of the evidence of record. See 38 C.F.R. §§ 3.102, 4.16. In so reaching the above conclusions, the Board has appropriately applied the benefit-of-the-doubt doctrine in this case. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER An evaluation in excess of 20 percent for right hip disability is denied. An initial evaluation in excess of 10 percent for right leg neuropathy is denied. Entitlement to TDIU is granted. ______________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs