Citation Nr: 1527468 Decision Date: 06/26/15 Archive Date: 07/07/15 DOCKET NO. 14-05 179 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to an initial compensable rating for osseous deformity, distal phalanx with stiffness in the interphalangeal joint, left thumb. 2. Entitlement to a total disability rating for individual unemployability due to service-connected disabilities (TDIU). 3. Entitlement to service connection for left shoulder disability. 4. Entitlement to service connection for a hypertension. ATTORNEY FOR THE BOARD Rachel Costello, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1989 to November 2009. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2013 and February 2013 rating decisions of the Department of the Veteran Affairs (VA) Regional Office (RO). The issue of entitlement to service connection for left shoulder disability and a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence reflects the Veteran's left thumb disability is manifested by complaints of flare-ups and occasional pain, swelling, and weakness in grip, with no objective evidence of limitation of motion with a gap of more than one inch between the thumb pad and fingers or ankylosis. 2. The Veteran's hypertension is not related to service. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for osseous deformity, distal phalanx with stiffness in the interphalangeal joint, left thumb, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71a Diagnostic Code 5228 (2014). 2. The criteria for service connection for hypertension are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In the present case, required notice was provided by letter dated in December 2011. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II); Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). As to VA's duty to assist, all necessary development has been accomplished. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's service treatment records and VA medical records have been obtained. Also, the Veteran was provided a VA examination of his claimed left thumb disability in December 2012, to include a January 2013 medical opinion, and February 2013. These examinations and their associated reports were adequate because, along with the other evidence of record, they provided sufficient information to decide the appeal and a sound basis for a decision on the Veteran's claim. The examination reports were based on examination of the Veteran by the examiner with appropriate expertise who thoroughly reviewed the claims file. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303 (2007). Furthermore, a VA examination was not obtained for the service connection claim for hypertension. As discussed below, there is no medical or other competent evidence suggesting a nexus between hypertension and service, or any other evidence that would warrant obtaining a medical nexus opinion. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, VA has satisfied its duties to notify and assist, and there is no prejudice to the Veteran in adjudicating this appeal. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Increased Rating The Veteran's left thumb disability is currently evaluated as 0 percent disabling under Diagnostic Code 5228. He seeks a higher initial rating. Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where the veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2014). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Under Diagnostic Code 5228, a 0 percent evaluation is assigned for limitation of motion of the thumb with a gap of less than one inch (2.5 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 10 percent evaluation is assigned for limitation of motion of the thumb with a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A 20 percent evaluation is assigned for limitation of motion of the thumb with a gap of more than two inches (5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5228 (2014). Under Diagnostic Code 5224, a 10 percent evaluation is assigned for favorable ankylosis of the thumb. A 20 percent evaluation is assigned for unfavorable ankylosis of the thumb. 38 C.F.R. § 4.71a, Diagnostic Code 5224 (2014). Consideration should also be given to whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function to the hand. 38 C.F.R. § 4.71a, Diagnostic Code 5224, Note (2014). Under Diagnostic Code 5152, a 20 percent evaluation is assigned for amputation of the thumb of the major hand at the distal joint or through the distal phalanx. A 30 percent is assigned for amputation of the thumb of the major hand at the metacarpophalangeal joint or through the proximal phalanx. A 40 percent evaluation is assigned for amputation of the thumb of the major hand with metacarpal resection. 38 C.F.R. § 4.71a, Diagnostic Code 5152 (2014). Ankylosis of the thumb is evaluated as amputation at the metacarpophalangeal joint or through the proximal phalanx if both the carpometacarpal and interphalangeal joints are ankylosed and either is in extension or full flexion, or if there is rotation or angulation of a bone. 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, (4) (i) (2014). Additionally, the evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran was afforded two VA examinations in association with his left thumb claim. The first examination, dated December 2012 notes the examiner reviewed the Veteran's clams file. The Veteran reported occasional swelling, pain, and weakness in grip of his left thumb, usually after use. He took Ibuprofen whenever he felt pain and swelling of his left thumb. He reported flare-ups, noting he felt pain and swelling at least once a week, usually when he woke-up. Pain lasts approximately three hours. He was limited in gripping and lifting due to pain in his left thumb during flare-ups. He reported he was right hand dominate. The examiner found the Veteran had limitation of motion or evidence of painful motion in the left thumb, but failed to record range of motion measurements. The examiner noted the Veteran was able to perform repetitive-use testing with three repetitions and there was no additional limitation of motion for any fingers post-test. There was no gap between the thumb pad and the fingers post-test. The examiner found that the Veteran had functional loss or functional impairment, but did not have additional limitation in range of motion of any of the fingers or thumbs following repetitive-use testing. The examiner found contributing factors of the disability were less movement than normal and pain on movement in the left thumb. The examiner found the Veteran did not have tenderness or pain to palpation for joints or soft tissue of either hand, including the thumbs and fingers. Muscle strength was normal, no ankylosis was found, and function was not so diminished that amputation with prosthesis would equally serve the Veteran. Diagnostic testing revealed osseous deformity, distal phalanx, left first digit, due to previous trauma. Joint space was intact. The right hand is unremarkable. The examiner opined that the Veteran's disability impacts his ability to work because he is mildly limited in gripping and lifting due to pain on his left thumb during flare-ups. The examiner diagnosed the Veteran with stiffness, interphalangeal joint of the left thumb. A January 2013 VA examination medical opinion notes the Veteran's most recent examination revealed pain and stiffness of the left thumb interphalangeal joint based on physical examination. The Veteran was more recently examined for his left thumb disability in February 2013. The examiner reviewed the Veteran's claims file and performed an in-person examination. At that time, he complained of flare-ups. The examiner found limitation of motion or evidence of painful motion in the left thumb. There was no gap between the thumb pad and the fingers, there was no gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with the fingertips, and no limitation of extension or evidence of painful motion for the index finger or long finger. The Veteran was able to perform repetitive-use testing with three repetitions and there was no additional limitation of motion for any post-test. The examiner found the Veteran had functional loss or functional impairment, noting he had less movement than normal, pain on movement, swelling, and deformity in his left thumb. No tenderness or pain to palpation for joints or soft tissue was found. Muscle strength was normal, no ankylosis was found, and function was not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner found the Veteran's hand disability impacted his ability to work, noting "see previous DBQ." The examiner confirmed the diagnosis of stiffness, interphalangeal joint, left thumb and osseous deformity, distal phalanx, thumb, due to trauma. The examiner noted that pain on movement of the left thumb, especially in opposing the small finger, was very mild. The Veteran was still able to oppose thumb to small finger. The Veteran was observed actively flexing interphalangeal joint of left thumb with ease when holding documents handed to him. X-ray shows intact interphalangeal joint of left thumb. The examiner further commented that swelling and deformity were checked during this examination because as the x-ray showed there was an osseous deformity and this osseous deformity was the cause of the bony enlargement or bony swelling, he palpated and observed over the area of the Veteran's interphalangeal joint, left thumb. Applying the facts to the rating criteria listed above, the Board finds the preponderance of the evidence is against the grant of a compensable rating for the service-connected left thumb disability at any point during the pendency of this appeal. The preponderance of the evidence shows that the left thumb disability is manifested by subjective complaints of occasional pain, swelling, and weakness in grip, usually after use, with objective evidence of less movement than normal, pain on movement, swelling, and deformity. Despite this evidence, the record does not show that the Veteran's left thumb is manifested by limitation of motion as contemplated by DC 5228. Indeed, while the Board notes that both the December 2012 and February 2013 VA examiners noted there was evidence of limitation of motion or painful motion of the thumb, the February 2013 VA examiner found there was no limitation of motion of the thumb with a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, even after repetitive motion. The December 2012 examiner also found there was no gap between the thumb pad and the fingers post-test. Thus, the Board finds the preponderance of the evidence does not show that the Veteran's left thumb is manifested by limitation of motion as contemplated by DC 5228. See 38 C.F.R. §4.71a, DC 5228. In reaching this determination, the Board acknowledges that pain on motion must be taken into account when rating a disability based on limitation of motion, even where there is compensable loss as a result of limitation of motion. DeLuca v. Brown, 8 Vet. App. at 205 -06. To receive disability compensation, however, for painful motion, that pain must result in functional loss, i.e., limitation in the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination or endurance." See 38 C.F.R. § 4.40; see also Mitchell, 25 Vet. App. at 38. In other words, "although pain may cause functional loss, pain itself does not constitute functional loss" that is compensable for VA benefit purposes. Mitchell, 25 Vet. App. at 37. Here, although the Veteran reported flare-ups and occasional pain, swelling, and weakness in grip of his left thumb, usually after use, and both VA examiners found the Veteran's hand condition impacted his ability to work because he is mildly limited in gripping and lifting due to pain in his left thumb during flare-ups, the Board finds that the disability rating currently assigned to the Veteran's left thumb disability adequately reflects the clinically established impairment experienced by the Veteran. The February 2013 VA examiner found the Veteran had no gap between the thumb pad and the finger, much less a gap of less than one inch, which is the criteria for a 0 percent rating under DC 5228. Moreover, the February 2013 VA examiner further noted that pain on movement of the left thumb, especially in opposing the small finger, was very mild. The Veteran was still able to oppose thumb to small finger. The Veteran was observed actively flexing interphalangeal joint of left thumb with ease when holding documents handed to him. Thus, taking the Veteran's reports of pain on flare-ups and overall hand function, the Board finds the disability rating currently assigned to the Veteran's left thumb disability adequately reflects the Veteran's impairment. The Board has considered the Veteran's left thumb disability under all other potentially applicable diagnostic codes; however, the Veteran's disability only involves his thumb and the evidence shows his disability is not manifested by ankylosis. Therefore, DCs 5224, which evaluates ankylosis of the thumb, and DCs 5229 and 5230, which evaluate limitation of motion of the index, long, ring, and little fingers, are not for application in this case. The Board has considered whether an extraschedular evaluation is warranted for the Veteran's issue on appeal. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2014). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, 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. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the Veteran's left thumb pain, swollenness, and weakness are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran has not expressly raised the matter of entitlement to an extraschedular rating. His contentions have been limited to those discussed above, i.e., that his left thumb disability is more severe than is reflected by the assigned ratings. As was explained in the merits of the decision above, the criteria for higher schedular ratings were considered, but the ratings assigned were upheld because the rating criteria are adequate. In view of the circumstances, the Board finds that the rating schedule is adequate, even in regard to the collective and combined effect of all of the Veteran's service connected disabilities, and that referral for extraschedular consideration is not warranted under the circumstances of this case. Johnson v. McDonald, 2013-7104, 2014 WL 3844196 (Fed. Cir. Aug. 6, 2014). Therefore, based on the foregoing reasons and bases, the Board finds the preponderance of the evidence is against the grant of an initial compensable rating for service-connected left thumb injury. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application and the Veteran's claim is denied. See Gilbert, supra. III. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110; 1131, 38 C.F.R. § 3.303(a) (2014). Service connection requires competent evidence showing the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2014). In addition, certain chronic diseases, such as hypertension, may be presumed to have been incurred during service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309; see also 67 Fed. Reg. 67792 -67793 (Nov. 7, 2002). The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson v. Shinseki, 581 F.3d 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). However, the Federal Circuit held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a), such as hypertension. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In determining whether service connection is warranted for a disability, VA must determine 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; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. The Veteran contends in his November 2011 claim that his hypertension began on August 29, 2006. In his April 2013 notice of disagreement, he avers that during his last years in service, his blood pressure increased to a point where a military physician had his blood pressure monitored for a month, after which he was asked to go on a diet (low on salt and fats and sufficient exercise). His doctor contemplated prescribing medicine at that time, but instead put the Veteran on a diet. He states his doctor mentioned that once he received hypertension medicine, it required continuation. He was then transferred to another duty station, where he saw different physicians, but his elevated blood pressure, causing pressure at the back of his neck near his head, remained constant. Service treatment records are silent for any treatment for, complaints of, or a diagnosis of hypertension. An April 2003 record notes the Veteran attended "TLC class" which provides instruction and information on major risk factors, interpretation of lab values, American Health Association low cholesterol diet, exercise and weight loss, atherosclerosis and heart disease, dietary fats and determining fat allowances, basic food groups and recommended servings, label reading and cooking alternatives, and information on hyperlipidemia medications, if applicable. In June 2003, a follow up lipid panel was ordered and the Veteran was instructed to go to the lab to have blood work drawn after 12 hours of fasting. An April 2004 preventive health assessment notes the Veteran reported he did not have a history of high blood pressure. A January 2006 record notes the Veteran had elevated lipids, added lipid panel for AM, and his blood pressure was 132/48. On a May 2007 report of medical history, the Veteran reported he was currently in good health. VA post-service medical records beginning in July 2011 note the Veteran had a history of hypertension. This history recounted that at age 35 in service the Veteran's usual blood pressure was 130/100, highest 140/120, but there was no maintenance medication; he was given an "unrecalled medication" which gave him a headache and there was no regular blood pressure monitoring. The record made a contemporaneous, July 2011 finding that the Veteran's hypertension was in stage 1; he was prescribed Lisinopril and advised to monitor his blood pressure daily. A June 2012 record notes the Veteran's hypertension was controlled. Upon careful consideration of the Veteran's allegations in conjunction with all the evidence of record, and for the reasons set forth below, the Board finds that the evidence weighs against the Veteran's service connection claim. While the Board recognizes the Veteran's assertion that his hypertension is related to service, the Veteran is not competent to make this conclusion. Although lay persons are competent to provide opinions on some medical issues, the specific disability in this case, hypertension, fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Hypertension requires specialized training and medical diagnostic testing for a determination as to diagnosis and causation, and is not susceptible of lay opinions on etiology. Therefore, the Board finds that the Veteran's statements of record cannot be accepted as competent evidence sufficient to establish service connection for hypertension. The Board has further found there is no competent medical opinion evidence that etiologically links any hypertension back to service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993). In this case, there are no positive medical findings or opinions in support of the Veteran's claims and neither the Veteran nor his representative have provided competent evidence, medical or lay, suggesting how hypertension relate back in any way to the Veteran's period of service. The Board acknowledges the July 2011 VA treatment record, which notes a history of hypertension and some attempt at prescribing medication therefore at "35" apparently during the Veteran's active duty service. However, the Board finds the information contained in the treatment record is a mere recitation of the Veteran's own reported history. Thus, as competent medical evidence of any nexus between current hypertension and service, the VA treatment record is of no probative value. See LeShore v. Brown, 8 Vet. App. 406 (1995). In any case, as was noted earlier, the Veteran's service treatment records do not relate problems with hypertension or to any such encounter with elevated blood pressure and the prescribing of medication, as described. Although the Veteran contends he was treated for hypertension in service, the Board does not find him credible. Service treatment records are silent for any complaints or findings of symptoms of hypertension in service. While the Veteran was treated for hyperlipidemia, there is no indication he was treated for hypertension as well. Moreover, as the record does not reflect any manifestation of hypertension within a year following discharge from service, the presumptive service connection provision of 38 C.F.R. §§ 3.307 and 3.309(a) for chronic disabilities are not applicable. Accordingly, the Board finds that service connection for hypertension is not warranted. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to a compensable disability rating for service-connected osseous deformity, distal phalanx with stiffness in the interphalangeal joint, left thumb, is denied. Entitlement to service connection for hypertension is denied. REMAND In regards to his claim for service connection for a left shoulder disability, the Veteran contends in his November 2011 claim that his injured shoulder began on December 17, 2005. In his April 2013 notice of disagreement he notes that during a morning physical training session, he sustained a physical injury. An April 1999 service treatment record notes the Veteran was playing basketball and had stiffness and pain the next morning. He could not move his neck or lift his shoulders. There was no history of previous injury or trauma. No numbness, tingling, or radiculopathy. The record notes "muscle strain," and the Veteran was given Motrin. An October 2005 record notes the Veteran was playing football three days ago and reported he was hit catching a ball. The next morning, his left shoulder was sore with limited movement. The Veteran reported some bruising on his forearm with bruising in the shoulder area. Left shoulder range of motion was to 80 degrees and the Veteran was positive for weakness and pain. The Veteran was given Motrin. A subsequent October 2005 record notes the Veteran complained of left shoulder pain for three weeks. He reported constant pain with sharp peaks. The Veteran requested to be waived from pushups. A December 2005 record notes the Veteran reported pain and loss of muscle strength in the left shoulder. He had a history of repeated injury. Magnetic resonance imaging (MRI) without signs of cuff tear, has osteophyte formation contouring the top of the supraspinatus muscle. A July 2006 report of medical history notes the Veteran reported swollen or painful joints, and wrote "shoulder bone spur- presently better." It further notes "shoulder pain-resolved," no numbness, tingling, and weakness. Full range of motion, good strength, able to "PT." On a May 2007 report of medical history, the Veteran reported he was currently in good health. VA post-service medical records beginning in July 2011 notes the Veteran complained of on and off pain in his left shoulder. Service treatment records (STRs) reveal the Veteran complained of left shoulder pain in service, a December 2005 record notes a MRI without signs of cuff tear, has osteophyte formation contouring the top of the supraspinatus muscle, and a July 2006 report of medical history notes the Veteran wrote "shoulder bone spur- presently better." As the STRs document repeated injuries to the left shoulder in service with evidence of some pathology on imaging studies, and post-service VA treatments records continue to reveal the Veteran has current complaints of on and off pain in his shoulder, the Board finds the Veteran should be afforded an examination, and an etiological opinion should be obtained to determine whether the Veteran has any left shoulder disabilities as a result of service. McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4). In regards to TDIU, the law provides that a total disability rating may be assigned where the schedular rating is less than total when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). When considering whether the Veteran's disabilities meet the above requirements, multiple disabilities may be considered as single disability under certain circumstances, such as when they arise from a common etiology or affecting a single body system. See 38 C.F.R. § 4.16(a)(2),(3). In this instance, service connection has been established for maxillary sinusitis with loss of smell (30 percent), posttraumatic stress disorder (PTSD) (30 percent), allergic rhinitis (10 percent), varicose veins of the left lower extremity (10 percent), varicose veins of the right lower extremity (10 percent) tinea corporis (0 percent), hordeolum, lower lid, left eye (0 percent), and osseous deformity, distal phalanx with stiffness in the interphalangeal joint, left thumb (0 percent). In this case the Veteran's sinusitis with loss of smell can be combined with allergic rhinitis to be considered a single disability because the affect a single body system or could stem from a common etiology. See 38 C.F.R. §§ 4.16(a)(2),(3), 4.25, and 4.26. Under the combined rating table, these disabilities combine to 40 percent rating. Id, Table 1. Therefore, the Veteran meets the percentage standards for a schedular TDIU rating. 38 C.F.R. § 4.16(a). The Veteran contends that he is entitled to a TDIU rating. Specifically, stating in his May 2015 claim that his service connected disabilities, to include his painful varicose veins, constant headaches and dizziness caused by rhinitis and high blood pressure, and lack of sleep caused by anxiety/PTSD, prevent him from being healthy. His conditions prevent him from leaving the house or driving a car to make it to a job interview or appointments. He further notes he has been seeking work for the pass two year, but has not gained any employment because of his disability, and if ever employed, he most definitely will stop going to work due to his disabilities. He additionally notes he is currently under a rehabilitation program at the VA in Manila. A May 2013 VA examination of the Veteran's varicose veins noted his vascular condition impacted his ability to work; causing mild/moderate restriction. A May 2013 VA examination of the Veteran's left eye found the Veteran's eye condition did not impact his ability to work. A June 2013 VA examination found the Veteran's loss of sense of smell did not impact his ability to work. A June 2013 VA psychiatric evaluation found the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or symptoms controlled by medication. An April 2015 VA examination of the Veteran's varicose veins noted his vascular condition impacted his ability to work. The examiner found there was mild restriction in his ability to obtain/retain sedentary and physical employment. The provisions of 38 C.F.R. § 4.17 require that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. In light of the foregoing, the Board finds a remand is necessary to associate VA treatment records from the rehabilitation program in Manila. Moreover, the Board finds the claim of entitlement to TDIU is inextricably intertwined with the service-connection claim for a left shoulder disability, as the outcome of the service-connection issue could potentially impact the outcome of the TDIU. Accordingly, the case is REMANDED for the following action: 1. Attempt to obtain and associate with the claims file any additional relevant evidence that may have come into existence since the claims folder was last before the AOJ, including any VA treatment records from the rehabilitation program in Manila. 2. The AOJ should then schedule the Veteran for an appropriate VA examination to determine the nature, extent, onset, and etiology of his claimed left shoulder disability. All indicated studies should be performed. The claims folder should be provided to the examiner(s) for review of pertinent documents therein in connection with the examination, and the examination report(s) should reflect that such a review was conducted. The examiner(s) should state whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's left shoulder disability was incurred in or as a result of active duty service, to include the injuries sustained during such service. A complete rationale for all opinions should be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner should explain whether inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. Upon review of all the evidence submitted, and any additional development deemed necessary, evaluate and adjudicate the left should disability and TDIU claims. If any benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs