Citation Nr: 1335156 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 07-01 676 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to a compensable evaluation for atrophy of the left testicle with low testosterone. 2. Entitlement to an evaluation in excess of 20 percent for residuals of bilateral inguinal hernia repair. 3. Entitlement to an initial evaluation in excess of 10 percent for left knee chondromalacia. 4. Entitlement to an evaluation in excess of 30 percent for depression. 5. Entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION The Veteran represented by: Robert K. Lemley, Agent WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from January 1980 to August 1981. He had additional service with the Army Reserve/National Guard, including a period of active duty for training from February to July 1978. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from March 2002, April 2005, and August 2005 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The procedural history of the claims remaining on appeal is as follows. In a March 2002 rating decision, the RO continued noncompensable ratings for left testicular atrophy and residuals of inguinal hernia repair and denied service connection for bronchitis and a left foot disability. The Veteran filed a notice of disagreement (NOD) and a statement of the case (SOC) was issued. In April 2003, he filed a timely substantive appeal (VA Form 9). The Veteran also filed a NOD with the initial 10 percent evaluation assigned for depression, for which service connection was granted in an April 2003 rating decision. In a March 2005 written statement, the Veteran withdrew all issues on appeal except for the issue of entitlement to a compensable evaluation for left testicular atrophy. On August 27, 2004, the Veteran filed a claim of entitlement to a TDIU. In an April 2005 rating decision, the RO continued noncompensable evaluations for left testicular atrophy and residuals of a bilateral inguinal hernia repair, continued a 10 percent evaluation for depression, and denied entitlement to a TDIU. The Veteran timely appealed each of these determinations. In an August 2009 rating decision, the RO increased the evaluation of his service-connected depression from 10 to 30 percent disabling effective August 27, 2004. This subsequent rating decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal. AB v. Brown, 6 Vet. App. 35 (1993). In an August 2005 rating decision, the RO granted service connection and assigned an initial noncompensable evaluation for left knee chondromalacia effective April 28, 2003. In August 2006, the Veteran filed a timely NOD with the initial evaluation assigned. In an August 2007 rating decision, the RO increased the disability evaluation from 0 to 10 percent effective April 28, 2003. The RO also issued a SOC regarding entitlement to an increased rating for left knee chondromalacia on August 7, 2007. On October 19, 2007, the RO received a statement from the Veteran indicating that he wished to continue his appeal of this issue. An undated letter in the claims file reflects that the RO determined that the Veteran's statement was untimely for the purposes of filing a substantive appeal. See 38 C.F.R. § 20.302 (2013) (A substantive appeal must be filed within 60 days from the date the agency of original jurisdiction (AOJ) mailed the SOC, or within the remainder of the 1-year period from the date of mailing of the notification of the determination being appealed). In August 2010, the Veteran testified at a Travel Board hearing before the undersigned Acting Veterans Law Judge; a transcript of the hearing is of record. In September 2011, the Board issued a decision. Although the issue of entitlement to an increased rating for left knee chondromalacia had not been certified to the Board, the Board accepted jurisdiction over the issue. See Percy v. Shinseki, 23 Vet. App. 37, 45 (2009) (VA may waive any issue of timeliness in the filing of a substantive appeal either explicitly or implicitly). The Board dismissed the issues of entitlement to service connection for bronchitis and a left foot disability, denied the issues of service connection for diabetes mellitus and peripheral neuropathy, denied earlier effective dates for the grant of a 20 percent evaluation for residuals of bilateral inguinal hernia repair and a 10 percent evaluation for left knee chondromalacia, and granted a 30 percent evaluation for service-connected vitiligo. The Board remanded the remaining issues to the AOJ for additional development. It is noted that the Board previously mischaracterized the issue of entitlement to an increased rating for depression to include both the time period prior to August 27, 2004 and the time period since that date. A review of the procedural history, however, reflects that the appeal originated from an August 27, 2004 claim of entitlement to a TDIU. As such, the period relevant to the appeal begins on that date. The Veteran also appealed the denial of his petition to reopen a previously denied claim of entitlement to service connection for pernicious anemia (megaloblastic anemia). Prior to returning this appeal to the Board, in an October 2012 rating decision, the AOJ granted service connection for this disability. As this decision represents a full grant of the benefits sought with respect to this issue, this matter is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). Referred Issue In February 2013, the Veteran submitted a statement indicating that he wished to reopen his previously denied claim of entitlement to service connection for peripheral neuropathy. As this issue has not been adjudicated by the AOJ, the Board does not have jurisdiction over it. Therefore, it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The record fails to demonstrate atrophy of both testicles. 2. During the pendency of the appeal, the residuals of the bilateral inguinal hernia repair have been manifested by recurrence of a small left inguinal hernia that was not palpable but apparent on a CT scan and a small right inguinal hernia that was readily reducible. 3. Since the effective date of service connection, left chondromalacia has been manifested by flexion limited to, at worst, 85 degrees with pain, but without limitation of extension or objective evidence of recurrent subluxation or lateral instability. 4. Since August 27, 2004, the Veteran's depression symptoms have been productive of occupational and social impairment with deficiencies in most areas. 5. Since August 27, 2004, the Veteran's service-connected disabilities preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a compensable evaluation for atrophy of the left testicle have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.115b, Diagnostic Code 7523 (2013). 2. The criteria for an evaluation in excess of 20 percent for residuals of bilateral inguinal hernia repair have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.118, Diagnostic Code 7338 (2013). 3. The criteria for an initial evaluation in excess of 10 percent for left knee chondromalacia have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2013). 4. With resolution of reasonable doubt in the Veteran's favor, the criteria for a 70 percent rating for depression have been met from August 27, 2004. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9434 (2013). 5. Resolving reasonable doubt in the Veteran's favor, the criteria for a TDIU due to service-connected disabilities are met from August 27, 2004. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Clams Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Regarding the disability evaluation for left knee chondromalacia, this issue arose from the Veteran's disagreement with the rating assigned in connection with the grant of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007); VAOPGCPREC 8-2003 (2003). The United States Court of Appeals for Veterans Claims (Court) has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as a disability rating) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105 (West 2002). Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Regarding the remaining claims, the Board finds that the requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. VA provided the Veteran with notice required under the VCAA in letters dated in December 2001, January 2004, August 2004, September 2004, September 2005, March 2006, November 2008, and September 2011. The Veteran was notified of the information and evidence needed to substantiate and complete the claims, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. To the extent the notice was provided after the initial determinations, the claims were later readjudicated in a supplemental statement of the case (SSOC) issued in October 2012; thereby curing any timing deficiency. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, VA obtained the Veteran's service treatment records (STRs), his records from the Social Security Administration (SSA), and all of the identified and available post-service VA and private treatment records relevant to the claims herein decided. The Veteran was also afforded VA examinations for disabilities at issue. For the reasons discussed below, the Board finds that the examinations are adequate to make a determination on the issues herein decided. The Veteran was also provided an opportunity to set forth his contentions during the hearing before the undersigned Acting Veterans Law Judge. During a conference held in connection with the August 2010 Board hearing, and during the hearing itself, the undersigned Acting Veterans Law Judge fulfilled VA's duties under 38 C.F.R. § 3.103. Neither the Veteran nor his representative has argued otherwise. In September 2011, the Board remanded the claims to provide additional VCAA notice and to provide VA examinations to assess the severity of the Veteran's left knee disability and to determine the effect of his service-connected disabilities on his ability to secure and follow substantially gainful employment. As the AOJ provided additional VCAA notice in September 2011 and scheduled the Veteran for the requested VA examinations, the Board finds that the AOJ substantially complied with the prior remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Disability Evaluations - General Considerations Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. 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.A. § 1155; 38 C.F.R. § 4.1. There are separate rating codes which identify the various disabilities. 38 C.F.R. Part 4. 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. Any reasonable doubt regarding the degree of disability is resolved in favor of the claimant. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the claimant. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of a claimant's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings, however, are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). Left Testicular Atrophy The Veteran's service-connected left testicular atrophy with low testosterone has been evaluated as noncompensable under Diagnostic Code 7523. 38 C.F.R. § 4.115(b). Under Diagnostic Code 7523, a noncompensable disability rating is assigned when there is atrophy of one testis and a 20 percent disability rating is assigned when there is atrophy of both testes. Id. The evidence reflects that the Veteran developed left testicular atrophy following left inguinal hernia repair and excision of a varicocele. The reports of VA examinations conducted in January 2002, February 2003, November 2004, and November 2008, as well as VA and private treatment records, indicate that the Veteran's left testicle was atrophied; however, atrophy of the right testicle was not shown. In November 2004, it was noted that the Veteran's right testicle appeared normal to palpation but was mild to moderately tender. A November 2006 VA outpatient treatment record reflects that the Veteran expressed concern over the viability of his right testicle and believed that it had become atrophic; however, the examining physician indicated that the right testicle was present and appeared viable. In November 2008, the examiner indicated that the Veteran's right testicle appeared to be normal in size and consistency. As the record fails to demonstrate any right testicular atrophy, a higher disability rating is not warranted under Diagnostic Code 7523. The Board has considered evaluating the Veteran's service-connected atrophy of the left testicle under other diagnostic codes in order to provide him with the most beneficial rating; however, Diagnostic Code 7523 is the most appropriate code, considering the Veteran's symptoms, as this is the only diagnostic code that addresses testicular atrophy. To the extent the Veteran also has low testosterone and complaints of sexual dysfunction, the Board notes that he is presently in receipt of special monthly compensation based on loss of use of a creative organ. See 38 U.S.C.A. § 1114(k) (West 2002 & Supp. 2013); 38 C.F.R. § 3.350 (2013). In reaching this decision, the Board considered the Veteran's lay statements. The Veteran is competent to report his observations with regard to the atrophy of his left testicle, his sexual dysfunction, and his concerns regarding his right testicle. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board also finds his statements to be credible and consistent with the evaluation assigned under Diagnostic Code 7523 and the award of special monthly compensation based on the loss of use of a creative organ. To the extent he argues his symptomatology is more severe, his statements must be weighed against the other evidence of record. Here, the specific examination findings of trained health care professionals are of greater probative weight than the Veteran's general lay assertions. In consideration of the above, the Board finds that entitlement to a compensable evaluation for atrophy of the left testicle with low testosterone is not warranted. Residuals of Bilateral Inguinal Hernia Repair The Veteran underwent surgical repair of a left inguinal hernia in 1979 and surgical repair of a right inguinal hernia in 1981. During the time period relevant to this appeal, the service-connected residuals have been evaluated as 20 percent disabling under Diagnostic Code 7338. 38 C.F.R. § 4.114. A temporary total disability evaluation is assigned from October 6, to November 30, 2006 for a period of convalescence following additional surgery that was required after the recurrence of the hernias. 38 C.F.R. § 4.30. Diagnostic Code 7338 provides that postoperative recurrent inguinal hernia, readily reducible, well supported by truss or belt, is rated 10 percent disabling. Small inguinal hernia, postoperative recurrent, or unoperated irremediable, not well supported by truss, or not readily reducible, is rated 30 percent disabling. Large inguinal hernia, postoperative recurrent, not well supported under ordinary conditions and not readily reducible, when considered inoperable, is rated 60 percent disabling. A Note to Code 7338 provides that 10 percent is to be added for bilateral involvement, provided the second hernia is compensable. This means that the more severely disabling hernia is to be rated, and 10 percent, only, added for the second hernia, if the second hernia is of compensable degree. Id. During a November 2003 VA examination, the Veteran reported that the scars healed nicely and only intermittently gave him symptoms. On physical examination, the scars were extremely well-healed and barely visible. The left scar measured 6 cm x 1 mm and was nontender to palpation. The right scar measured 4 cm x 1 mm and was mildly tender to palpation. There was a very small defect of the right inguinal hernia, but no evidence of "gross failure of the right hernia." The assessment was residual scars, post right and left inguinal hernia and left varicocelectomy and mild recurrent right inguinal hernia. In a July 2004 letter, a private physician (Dr. O.G.I.) noted the Veteran's complaints of right groin pain since his testicular surgery. The physician noted that the pain was on the line of the surgical incision and suggested that it might be related to a neuroma along the incision line. During a November 2004 VA examination, the Veteran reported that he felt as if he had recurrence of the right inguinal hernia for the past year and that it was gradually worsening. He said he had intermittent daily pain in the right testicular and inguinal area that could last up to three hours at a time. On physical examination, there was no hernia recurrence observed in either the right or left inguinal areas. The right testicle was normal, but was mild to moderately tender. A September 2006 VA outpatient treatment note reflects that the Veteran had recurrence of a right inguinal hernia and possible left inguinal hernia. Palpation of the left groin revealed no hernia defect or bulge. There was a reducible hernia on the right groin. The review of a CT scan performed at Methodist Hospital in May 2006 revealed a right inguinal hernia measuring 4.4 cm and a left inguinal hernia measuring 2.4 cm. The Veteran was scheduled for a bilateral inguinal hernia repair, which was performed in October 2006. During a November 2008 VA examination, the Veteran reported that he had intermittent pain in the right groin, which occurred three to four times per week, five to six times per day. He described the pain as sharp and shooting with an average intensity of 10/10 that lasted 40 to 50 seconds. He said he was not aware of any hernia recurrence. On physical examination, there was no recurrence of inguinal hernias detected. There was no localized tenderness or palpable mass. During an October 2011 VA examination, the Veteran reported that he had some residual pain in the left inguinal area. On physical examination, there were bilateral herniorrhaphy scars, which were linear, nontender, superficial, and not associated with any underlying tissue loss, edema, keloid formation, or inflammation. There was no evidence of inguinal hernia. There was some tenderness when the examining finger was inserted high into the inguinal canal on the left. The assessment was bilateral inguinal hernias with recurrence and repair, residual mild left inguinal pain without history of incarceration or bowel obstruction or other complications. Based on the foregoing evidence, the Board finds that an evaluation in excess of 20 percent is not warranted for residuals of bilateral inguinal hernia repair. The evidence reflects that the Veteran has had postoperative recurrent hernias. The left inguinal hernia was not palpable, but was apparent on a CT scan. The right inguinal hernia was palpable but easily reducible. Since the October 2006 surgery, there have been no recurrences. Hence, the Veteran's symptoms are commensurate with a 10 percent rating under Diagnostic Code 7338 with an additional 10 percent added for bilateral involvement. To warrant an evaluation higher than 20 percent, the evidence must show small inguinal hernia that is either not well supported by truss or not readily reducible. The evidence does not reflect that the Veteran wore a hernia truss or that one was recommended. To the extent that he had recurrence of a small palpable right inguinal hernia, it was noted to be readily reducible. As such, the Board finds that the Veteran's symptomatology is most consistent with the criteria for a 20 percent rating. In various statements, the Veteran has argued that he is entitled to separate compensable ratings for the surgical scars resulting from the bilateral herniorrhaphy. The Board notes that the evaluation of scars was amended as of October 23, 2008. However, these particular revisions are only applicable to applications for benefits received by VA on or after October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). Here, VA received the Veteran's claim in August 2004. Therefore, only the pre-October 2008 version of the schedular criteria is applicable in this case. The evidence reflects that the Veteran's surgical scars are well-healed, superficial, stable, cover an area of less than 144 square inches, and do not cause limitation of motion. Therefore Diagnostic Codes 7801, 7802, 7803, and 7805 are not applicable. 38 C.F.R. § 4.118 (prior to October 23, 2008). Diagnostic Code 7804 provides a 10 percent disability rating for superficial scars that are painful on examination. Id. In this case, there is some discrepancy as to whether the scars themselves are painful or whether the tenderness noted was a result of inguinal hernias. In November 2003, a mild right inguinal hernia recurrence was noted and the scar was noted to be mildly tender to palpation; however, the scar was described as well-healed and barely visible. In July 2004, Dr. O.G.I. noted that the Veteran had pain on the line of the incision in the right groin and thought it might be a neuroma, but further testing revealed recurrence of an inguinal hernia. As noted, the Veteran underwent bilateral inguinal hernia repair in October 2006. Post-recovery, in November 2008, there was no localized tenderness or palpable mass. In October 2011, the scars were noted to be superficial and nontender. The preponderance of the evidence indicates that the Veteran had tenderness and pain associated with the recurrence of the inguinal hernias, but that this pain was not associated with the superficial surgical scars, which were barely visible. For these reasons, the Board finds that the evidence weighs against assigning separate 10 percent ratings for the surgical scars. In reaching this decision, the Board considered the Veteran's lay statements. The Veteran is competent to report his observations with regard to the recurrence of inguinal hernias and associated pain. See Jandreau, 492 F.3d at 1376-77. The Board also finds his statements to be credible and consistent with the evaluation assigned. To the extent he argues his symptomatology is more severe, his statements must be weighed against the other evidence of record. Here, the specific examination findings of trained health care professionals are of greater probative weight than the Veteran's general lay assertions. In consideration of the above, the Board finds that entitlement to an evaluation in excess of 20 percent for residuals of bilateral inguinal hernia repair is not warranted. Left Knee Chondromalacia 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. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. When evaluating disabilities of the joints, VA's Rating Schedule provides for consideration of additional functional impairment due to pain, weakness, fatigue, incoordination, and lack of endurance when assigning evaluations. 38 C.F.R. §§ 4.40, 4.45, 4.59; see DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran's left knee chondromalacia has been evaluated as 10 percent disabling under Diagnostic Code 5260, for limitation of flexion of the leg. 38 C.F.R. § 4.71a. Evaluations for limitation of flexion of a knee are assigned as follows: flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a , Diagnostic Code 5260. Evaluations for limitation of knee extension are assigned as follows: extension limited to 5 degrees is 0 percent, extension limited to 10 degrees is 10 percent; extension limited to 15 degrees is 20 percent; extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2013). Normal range of motion of a knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (2013). VA is required to provide separate evaluations for separate manifestations of the same disability which are not duplicative or overlapping. 38 C.F.R. § 4.14 (2013); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). In that regard, separate evaluations may be assigned for non-overlapping manifestations of knee disability. See VAOPGCPREC 9-2004, published at 69 Fed. Reg. 59,990 (Oct. 6, 2004) (separate ratings for limitation of flexion and extension of the knee); VAOPGCPREC 9-98, published at 63 Fed. Reg. 56,703 -04 (Oct. 22, 1998) (separate ratings for instability and limitation of motion); VAOPGCPREC 23-97, published at 62 Fed. Reg. 63,604 (Dec. 1, 1997) (to the same effect). The combined evaluation for the affected leg, however, cannot exceed the rating for amputation at the elective, were amputation to be performed. 38 C.F.R. § 4.68 (2013). As discussed below, there is some evidence suggesting that the Veteran has left knee degenerative joint disease (DJD) in addition to chondromalacia. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). In this case, there is no medical evidence distinguishing the symptoms attributable to the Veteran's left knee chondromalacia from his nonservice-connected DJD. Hence, the Board has considered all of the Veteran's left knee symptoms in evaluating his service-connected chondromalacia. During a February 2003 VA examination, the Veteran complained of constant bilateral knee pain. He said the pain was worse when climbing stairs and diminished with heat and nonweightbearing. He said he was able to do the activities of daily living, but required assistance dressing. He was only able to walk half a block before having to stop because of pain. He said he intermittently used a cane and crutches for support. On physical examination, there were no appreciable scars or joint deformities. There was moderate tenderness to deep palpation over the medial and lateral aspects of the knees. There was no effusion or muscle atrophy. Motor strength was 5/5. He had full extension of the left knee. Flexion was limited at 85 degrees by pain. There was no evidence of joint laxity of the mediolateral or collateral ligaments. Anterior and posterior drawer signs were negative. X-rays were normal. The impression was chondromalacia. During a November 2003 VA examination, the Veteran reported that his left knee continued to bother him and that it gave out. He also complained of some swelling and difficulty going up and down stairs. He said he avoided kneeling. On physical examination, he had full extension of the left knee. Flexion was limited to 123 degrees by body habitus. He had good end points with varus and valgus stress tests and anterior and posterior drawer tests. The examiner indicated that the ligaments were stable. There was no tenderness to palpation along the medial joint line, but there was significant discomfort with palpation and patellar grind test. The patella appeared to be tracking well. There was no posterolateral instability. X-rays revealed a very slight varus deformity with good preservation of his medial and lateral compartments. The assessment was mild chondromalacia of the patella. The report of a November 2004 VA examination reveals the Veteran's complaints of continuous pain, giving way, and locking. He reported that he had difficulty standing from a sitting position, kneeling, and squatting. On physical examination the knees revealed no external deformity, intra-articular fluid, or localized tenderness. Range of motion of the left knee was from 0 degrees of extension to 95 degrees of flexion with pain occurring at 95 degrees. Active and passive range of motion were unaffected by repetition. There was no limitation due to weakness, fatigue, incoordination, or flare-ups. His gait was normal. X-rays were normal. The diagnosis was mild strain of both knees. In April 2005, the Veteran underwent an assessment for SSA disability purposes. The physician noted that there was moderate tenderness of the left knee and mild swelling. Range of motion was decreased; however there was no edema or atrophy present. An April 2005 x-ray from Methodist Hospital showed no abnormalities of the left knee. A February 2007 VA outpatient treatment record indicates the Veteran had anterior superficial swelling of the left knee with deep achy pain. Range of motion was from 0 degrees of extension to 100 degrees of flexion. There was no varus/valgus instability and no medial or lateral joint line tenderness. Lachman and McMurray tests were negative. Prepatellar swelling and tenderness to palpation were noted. X-rays of the left knee showed mild patellar spurring and normal joint space. The assessment was prepatellar bursitis. In April 2007, a MRI of the left knee was reviewed; there was no evidence of meniscal or joint pathology. Physical therapy and quadriceps strengthening were recommended. During a November 2008 VA examination, the Veteran complained of continuous daily left knee pain exacerbated by climbing stairs, walking more than 50 feet, or standing more than 15 minutes. He reported having stiffness after sitting for more than seven minutes. He said that his knees occasionally locked twice a week and gave out infrequently. Because of instability, he said that he used a cane. On physical examination, range of motion of the left knee was from 0 degrees of extension to 120 degrees of flexion with pain but no functional limitation. Range of motion testing during passive, active, and after three repetitions was the same. There was no additional functional impairment due to pain, weakness, fatigability, incoordination, or flare-ups. There was minimal crepitus, but no inflammation or intra-articular fluid. The joint was stable with intact ligament function. Gait and station revealed a mild limp. It was noted that an October 2008 MRI of the left knee showed degenerative joint disease and a strain of the anterior cruciate ligament (ACL) and medical collateral ligament (MCL). The diagnosis was mild chondromalacia with degenerative arthritis and strain of the ACL and MCL. The report of an October 2011 VA examination reveals the Veteran's complaints of left knee pain, difficulty walking any great distances, and difficulty climbing stairs. He said he used a cane because of loss of equilibrium, but this was noted to be the likely result of peripheral neuropathy rather than chondromalacia. On physical examination, range of motion of the left knee was from 0 degrees of extension to 120 degrees of flexion with mild pain at 120 degrees. There was no loss of joint function with use due to pain, weakness, fatigability, incoordination, or flare-ups. The lower extremities revealed a mild genu varum deformity. The left knee showed no evidence of joint swelling or capsular thickening. The collateral and cruciate ligaments were intact and there was no rotary instability. There was discomfort with compression of the patella. Crepitation was not elicited. Deep tendon reflexes were normal. The examiner indicated that there was no evidence of any functional loss to the left knee itself and that the Veteran's obesity and past history of peripheral neuropathy secondary to pernicious anemia were likely contributing to his discomfort. The knee itself was stable and there was no laxity present. X-rays revealed mild DJD with minimal patellar osteophyte formation. The diagnosis was chondromalacia. In this case, the Board finds that a rating in excess of 10 percent for the Veteran's left knee disability is not warranted. To warrant a higher 20 percent rating under Diagnostic Code 5260, the evidence must show limitation of flexion to 30 degrees or less. Here, at worst, the Veteran's left knee flexion was limited to 85 degrees in February 2003. This measurement falls below the threshold required for a zero percent evaluation under Diagnostic Code 5260. The Veteran has described symptoms of pain and stiffness exacerbated by walking, standing, and sitting; however, these symptoms have not been shown to reduce function of the left knee to the degree contemplated for a 20 percent rating under Diagnostic Code 5260. At no point has there been credible evidence that there has been the functional equivalent of limitation of flexion to 45 degrees or less due to any factor. As such, an initial rating higher than 10 percent for left knee chondromalacia is not warranted. As noted, the record reflects that the Veteran has increased pain with activity and repetitive motion; however, the examiners indicated that there was no additional functional limitation on repetitive testing and no limitation due to weakness, fatigue, incoordination, or flare-ups. Therefore, the Board finds that the 10 percent rating assigned is consistent with DeLuca, 38 C.F.R. § 4.40, 4.45, and 4.59 (recognizing the intention of the rating schedule to recognize actually painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint). Moreover, the Board finds that a separate rating for limitation of extension and/or instability is not warranted. The evidence does not reflect that the Veteran has had any limitation of extension of the left knee. The Board notes that the Veteran has reported a sensation of instability and giving way; however, the objective evidence indicates that he does not have lateral instability or subluxation in the left knee. Although an October 2008 MRI showed a strain of the ACL and MCL, the ligaments were noted to be clinically stable and the ligaments intact. Varus/valgus stress tests and anterior drawer tests were repeatedly negative for instability. The Board acknowledges that the Veteran is competent to describe the sensation of instability or giving way and finds that his statements are credible in this regard. Here, however, the Board finds the medical findings elicited by skilled provisions are more probative and, as noted above, do not provide for a separate compensable rating for lateral instability or recurrent subluxation. The Board has also considered whether there is any basis for assignment of any higher ratings for the left knee disability under any other potentially applicable diagnostic code. However, the Veteran's left knee symptomatology has not included ankylosis, the removal of cartilage, dislocated cartilage, impairment of the tibia or fibular, or genu recurvatum; hence, Diagnostic Codes 5256, 5258, 5259, 5262 and 5263 are not applicable. Depression At the outset, the Board notes that the Veteran has been service connected for depression associated with his service-connected left testicular atrophy. The evidence, however, indicates that the Veteran's depression is primarily a result of his various medical conditions - both service-connected and nonservice-connected. In addition, he has been diagnosed with an anxiety disorder; however, it is unclear whether this disorder is related to service or service-connected disability. As noted above, where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider, 11 Vet. App. at 181. In this case, there is no medical evidence distinguishing the Veteran's psychiatric symptoms attributable to service-connected disabilities from nonservice-connected disabilities. Hence, the Board has considered all of the Veteran's psychiatric symptoms in evaluating his service-connected depression. The Veteran's depression has been evaluated as 30 percent disabling under Diagnostic Code 9434; however, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Under the formula, a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the "American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders" (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Considering the pertinent evidence in light of the applicable criteria and affording the Veteran the benefit of the doubt, the Board finds that a 70 percent rating, but no higher, is warranted for depression throughout the appeal period. An April 2004 summary from Methodist Hospital notes a discharge diagnosis of depressive disorder. A July 2004 VA social work progress note reflects that the Veteran continued to struggle with a variety of medical problems. He was especially self-conscious about his service-connected skin disorder and avoided social settings because of it. He also said secondary complications further depressed him. During a November 2004 VA examination, the Veteran reported worsening depression associated with his medical problems and inability to work. He reported having crying spells, irritability, anger, difficulty concentrating, and difficulty falling and staying asleep. He said that he was single and lived in a house with a roommate. He said he had four children. Regarding suicidal ideation, he said that he thought he would rather be dead, but refused to answer whether he thought about taking his own life. He said he last worked in 2000, but was fired because of his attitude. On mental status evaluation, he was cooperative, although a little tense. His speech was spontaneous. There were no motor abnormalities. His affect was appropriate to thought content. His mood was even. He was well-oriented to time, place, person and to the month, but not the exact date. He denied any auditory or visual hallucinations. Some difficulties with abstract thinking were noted. He was able to repeat the days of the week in reverse order; however he was unable to recall three items after four minutes. The examiner diagnosed the Veteran with major depression with a GAF score of 61 to 65. The examiner opined that it was unlikely that his depression made him unable to seek, gain, and maintain employment. During an April 2005 evaluation for SSA disability benefits, the Veteran reported that he was depressed and sad most of the time. He reported that he was hospitalized in 1990 for suicidal ideation, but had no current suicidal thoughts. He was alert and oriented to person, place and thing. His affect was depressed and he cried several times during the evaluation. His dress and behavior were appropriate and his mental capacities appeared grossly normal. A January 2008 VA psychiatry note reflects that the Veteran was concerned about his medical problems. He said he only slept four hours per night. He was very angry and tearful when he discussed his medical and family problems. He said he avoided driving because of panic attacks. He had phobias of water and heights and had difficulty going to the grocery store. He had a history of multiple marriages, which reportedly dissolved due to mood swings. He had four children, but said he did not have relationships with any of them. He lived with his father. On mental status evaluation, he made good eye contact, had good grooming and hygiene, and was very loud when angry. When calm, his speech had normal rate and rhythm. His mood was depressed and his affect was tearful frequently. He was alert and oriented. His thought processes were goal-directed. Thought content was preoccupied with being done wrong and trying to get some sort of compensation. He denied suicidal and homicidal ideation. He also denied audio and visual hallucinations. He exhibited some paranoia, but judgment and insight were noted to be good. The diagnoses were depressive disorder and anxiety disorder. The psychiatrist assigned a GAF score of 50 and prescribed citalopram for anxiety and temazepam for insomnia. In March 2008, he reported having daily feelings of sadness and depression and sometimes having crying spells. He did not feel that citalopram had done much, but he seemed a bit more control of his feelings during the interview. In April, June, July and August 2008, similar symptoms were reported and GAF scores of 50 were assigned. In July, he reported feeling socially shunned because of his service-connected vitiligo. He said he dealt with his anger by not interacting with people too much. His psychiatrist described his symptoms as severe in July and moderately severe in August 2008. In a June 2008 letter, the Veteran's VA treating psychiatrist (Dr. C.P.) indicated that she had been treating him for depression and anxiety since January 2008. She said he had worsened problems with depression and anxiety associated with current life stress, including some service-related medical problems and family stressors. The report of a November 2008 VA examination reflects the Veteran's complaints of emotional problems, difficulty dealing with his medical issues, frustration, irritability, anger, feeling helpless, difficulty concentrating, difficulty sleeping, and feelings of insecurity and guilt. He indicated he was unable to work because of "health problems." He also indicated that he had no social life. Regarding suicidal ideation, he said he had thought about not wanting to live and had intermittent thoughts of taking his own life. He said that he would not tell the examiner if he had any plan or intent and would not tell his psychiatrist or therapist if he had these thoughts. On mental status evaluation, he was condescending, irritable, reluctantly cooperative, but not totally unpleasant. His affect was wary and varied. He became emotional at times; his mood seemed "smoldering." He was oriented to time, place, person, and date. There was no evidence of any perceptual disorder. Some difficulties with abstract thinking were noted. His concentration and judgment were intact. After four minutes, he was able to recall two out of three items. The diagnosis was major depressive disorder with a GAF score of 60. The examiner opined that it was "as likely as not that his depression makes him unable to engage in physical or sedentary employment." A February 2009 VA psychiatry note reflects that the Veteran was stressed due to his own illness and the illness of his father. He reported having panic attacks while driving on the highway. He became tearful when discussing his family. It was noted that he had some depression and a fair amount of anxiety. His affect was appropriate. He denied suicidal and homicidal ideation. A GAF score of 45 was assigned. In April 2009, he acknowledged having fleeting or passive suicidal ideation, but said that he did not "let thoughts like that get to [him]." His major depression was described as moderate. A GAF score of 50 was assigned. A May 2012 VA social work progress note reflects that the Veteran continued to struggle with medical issues, depression, and financial problems. It was noted that he had past involvement in the mental health clinic, but financial and transportation issues impeded his attendance. As an initial matter, the Board finds the examination reports during this time period are adequate as the examiners reviewed the claims file and pertinent history, examined the Veteran and provided findings and rationales in sufficient detail, and where applicable, provided clarification. The VA examination reports, considered cumulatively, are thorough and supported by the record. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). During this time period, the Board finds the Veteran exhibited some psychiatric symptoms among the criteria for a 70 percent rating and some symptoms among the criteria for 30 and 50 percent ratings. Resolving reasonable doubt in the Veteran's favor, the Board finds that a 70 percent rating is warranted. In this regard, the Board notes that the Veteran exhibited near-continuous depression and described being sad most of the time and having occasional crying spells. He frequently became tearful during his evaluations. He also frequently endorsed passive suicidal ideation, although without intent or plan. He exhibited impairment in abstract thinking, memory, and concentration. He reported and exhibited frustration, anger outbursts, and irritability. He avoided social contact, had a history of four failed marriages, and described very troubled family relationships. Although he attributed his unemployability to his health problems, the November 2008 examiner opined that his depression as likely as not made him unable to engage in employment. Resolving reasonable doubt in his favor, the Board finds that his symptoms resulted in deficiencies in most areas (i.e., thinking, family relations, work, and mood). The Board notes that the assigned GAF scores ranging from 60 to 65 during this time period are suggestive of less impairment than contemplated in the criteria for a 70 percent rating. According to the DSM-IV, GAF scores of 61 to 70 are indicative of some mild symptoms and GAF scores of 51 to 60 are indicate of moderate symptoms. The GAF scores of 45 and 50 are indicative of serious symptoms such as suicidal ideation and serious impairment in social and occupational impairment. These GAF scores are consistent with the criteria for a 70 percent rating. In this case, the evidence does not reflect total occupational and social impairment due to the Veteran's psychiatric symptoms. He did not exhibit symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for the names of close relatives, own occupation, or own name. Moreover, he did not exhibit symptoms of similar severity, frequency, or duration. While he had some impairment in abstract thinking, he did not exhibit gross impairment in ether thought processes or communication. To the extent he exhibited depression and passive suicidal ideation, these symptoms were not so severe as represent a persistent danger of hurting himself or an intermittent inability to perform activities of daily living. While he had impaired ability to remember three items after four minutes, he did not exhibit memory loss of such severity as to not remember his own name, the names of relatives, or his former occupation. Collectively, the evidence reflects that neither the Veteran's symptoms nor his overall level of impairment more nearly approximate the total occupational and social impairment required for a 100 percent rating. In reaching this decision, the Board considered the Veteran's lay statements. The Veteran is competent to report his psychiatric symptoms, including depression, anger, frustration, irritability, difficulty sleeping and concentrating, and suicidal ideation. See Jandreau, 492 F.3d at 1376-77. The Board also finds his statements to be credible and consistent with the evaluation assigned. To the extent he argues his symptomatology is more severe, his statements must be weighed against the other evidence of record. Here, the specific examination findings of trained health care professionals are of greater probative weight than the Veteran's general lay assertions. In consideration of the above, the Board finds that a 70 percent rating, but no higher, is warranted for depression throughout the appeal period. Extra-Schedular Consideration As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms described by the Veteran are contemplated by the applicable rating criteria. Regarding residuals of hernia repair, the rating criteria contemplate recurrence along with the size and severity of the hernia. Regarding left testicle atrophy, the rating criteria address whether one or both testes are atrophied and provide for consideration of special monthly compensation based on loss of use of a creative organ, which has been assigned in this case. Regarding left knee chondromalacia, the rating criteria contemplate functional limitations due to pain and limited mobility. Regarding depression, the criteria contemplate the frequency and severity of depressive symptoms and their impact of social and occupational functioning. With respect to each disability, higher ratings are available for more severe symptomatology. Hence, the evidence compels the conclusion that the degree of impairment in this case does not rise to the level that application of the regular schedular standards are impractical. Therefore, referral for consideration of an extraschedular rating for disabilities at issue is not warranted. 38 C.F.R. § 3.321(b)(1). TDIU Total disability ratings for compensation based upon individual unemployability 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 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. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2013). Given the decision above, the Veteran meets the objective, minimum percentage requirements, set forth in 38 C.F.R. § 4.16(a), for consideration of a schedular total disability evaluation based on individual unemployability due to service connected disorders since the date of his August 27, 2004 claim for individual unemployability. The Veteran is in receipt of a 70 percent rating for depression, a 30 percent evaluation for vitiligo, a 20 percent rating for residuals of bilateral inguinal hernia repair, 10 percent ratings for right and left knee chondromalacia, and noncompensable ratings for atrophy of the left testicle and anemia. The remaining question is whether the Veteran's service-connected disabilities alone have rendered him unemployable. See 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether a Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In adjudicating a claim for benefits VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(b). Considering the entire record in light of the above, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the evidence supports the assignment of a TDIU due to service connected disorders as of the date of the Veteran's claim on August 27, 2004. The evidence supporting assignment of a TDIU consists of an April 2005 SSA decision and supporting medical records and the November 2008 VA psychiatric examiner's opinion. According to the April 2005 SSA decision, the Veteran was found to be disabled from June 2003 due to a multiple medical problems, including joint pain and depression. It was noted that the Veteran had a GED education and that his past work experience included a barber, security officer, corrections officer, and food service manager. It was noted that a vocational expert testified that the Veteran's former job as a food service manager at Burger King was semi-skilled, sedentary work, and could be performed despite his restrictions. The expert noted that only severe loss of bilateral manual dexterity would interfere with his ability to work in that job. The Administrative Law Judge noted that the Veteran could perform that type of work through June 2003, but that he was unable to go through postural and range of motion testing during a June 2003 evaluation. That, coupled with a June 2003 diagnosis of moderate depression, worsening carpal tunnel syndrome, additional ambulatory an postural restrictions due to pain, led to the determination that he was restricted to simple, repetitive work effective June 2003 and that he was unable to sit, stand and/or walk in any combination for the duration of an eight-hour day. Because he could not work on a regular and continuing basis, he was determined disabled from June 2003. The Board notes, however, that the SSA decision takes into account both service-connected and nonservice-connected disabilities. As noted above, the November 2008 VA psychiatric examiner opined that based on the information in the record and gained during the examination, it was "as likely as not" that the Veteran's depression made him unable to engage in physical or sedentary employment. Although the examiner did not provide an explicit rationale for her opinion, the Board notes that she is a Board-certified psychiatrist and that her opinion was based on the evidence of record and an in-person evaluation of the Veteran. The Court has emphasized that medical reports must be read as a whole and in the context of the evidence of record. Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). For these reasons, the Board finds the November 2008 VA examiner's opinion both competent and probative evidence supporting the Veteran's claim. The evidence weighing against the assignment of a TDIU consists of the opinions rendered by VA examiners in November 2004 and November 2008. In November 2004, the Veteran underwent VA general medical and psychiatric examinations. The psychiatric examiner opined that it was unlikely that the Veteran's depression made him unable to seek, gain, and maintain employment. The general medical examiner opined that the Veteran was employable but that he should be restricted to work in a seated position that allowed him to take frequent breaks. The November 2008 VA general medical examiner likewise opined that the Veteran was able to perform desk-type work and was "not unemployable." The Board notes that the November 2004 VA examiners did not have access to the Veteran's SSA records at the time they rendered their opinions. Furthermore, it is unclear whether any of these examiners considered the Veteran's education and prior occupation when formulating their opinions. The Board observes that a manager at a fast food restaurant is not a "desk-type job," although some of the work might require sitting at a desk. Furthermore, it is difficult to conclude that this type of employment would allow for the Veteran to work only in a seated position and take frequent breaks. Given the evidence noted above, the Board finds that at a very minimum, the competent evidence is at least evenly balanced on the question of whether the nature and severity of the combined impact of the Veteran's service-connected disabilities prevents him from securing and following substantially gainful employment. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107. Given the evidence noted above, and with resolution of reasonable doubt in the Veteran's favor, the Board finds that entitlement to a TDIU due to service-connected disabilities from the date of his August 27, 2004 claim is established. Conclusion In this case, the Board concludes that a compensable rating is not warranted for atrophy of the left testicle, a rating higher than 20 percent is not warranted for residuals of bilateral inguinal repair, and a rating higher than 10 percent is not warranted for left knee chondromalacia. A 70 percent rating is warranted for depression from August 27, 2004 and a TDIU is also warranted as of that date. In reaching this decision, the Board has favorably applied the benefit-of-the-doubt doctrine; however, the Board finds that the preponderance is against assignment of any higher ratings. See 38 U.S.C.A. § 5107(b) ; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). (CONTINUED ON NEXT PAGE) ORDER A compensable evaluation for atrophy of the left testicle with low testosterone is denied. An evaluation in excess of 20 percent for residuals of bilateral inguinal hernia repair is denied. An initial evaluation in excess of 10 percent for left knee chondromalacia is denied. A 70 percent rating for depression from August 27, 2004 is granted, subject to statutory and regulatory provisions governing the payment of monetary benefits. Entitlement to a TDIU due to service-connected disabilities from August 27, 2004 is granted, subject to statutory and regulatory provisions governing the payment of monetary benefits. ____________________________________________ K. A. KENNERLY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs