Citation Nr: 1604730 Decision Date: 02/08/16 Archive Date: 02/18/16 DOCKET NO. 09-06 329 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for a low back disorder. 2. Entitlement to service connection for a sprain of the right upper extremity, claimed as a shoulder and arm disorder. 3. Entitlement to an increased rating for residuals of a puncture wound, right hand with periarticular osteopenia and osteoarthritis, in excess of 10 percent prior to November 23, 2011, and 50 percent therefrom. 4. Entitlement to increased initial ratings for bilateral hearing loss, initially rated noncompensable prior to November 21, 2011, 10 percent from November 21, 2011, to October 13, 2014, and 40 percent thereafter. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from March 1956 to April 1960. This case comes to the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Phoenix, Arizona, Regional Office (RO) and the Los Angeles, California, RO of the Department of Veterans Affairs (VA). The case is currently under the jurisdiction of the RO in Phoenix, Arizona. It is noted that the Veteran requested a Travel Board Hearing in his January 2009 substantive appeal; however, in an August 2009 statement he indicated that his request for a hearing should be withdrawn. Thus, his hearing request is deemed withdrawn. 38 C.F.R. § 20.704(d) (2015). The case was remanded by the Board in November 2013 so that additional VA and private medical records could be obtained and VA examinations conducted. These actions have been accomplished and the case has been returned for further appellate consideration. Following remand by the Board, the rating of the Veteran's bilateral hearing loss was increased to 40 percent. As he continues to express dissatisfaction with this rating, and it is less than the maximum under the applicable criteria, the claim remains on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. A low back disability was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 2. A right shoulder or arm disability was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. 3. Prior to November 23, 2011, the Veteran's right hand disability was primarily manifested by wrist range of motion from 0 to 40 degrees dorsiflexion, 0 to 50 degrees palmar flexion, 20 degrees of ulnar deviation, and 20 degrees of radial deviation. Range of motion of the fingers was from 0 to 90 degrees metacarpophalangeal (MCP) joint, 0 to 100 degrees proximal interphalangeal (PIP) joint, and 0 to 70 degrees distal interphalangeal (DIP) joint. 4. As of November 23, 2011, and thereafter, the Veteran's right hand disability was primarily manifested by limitation of PIP joints to 90 degrees, MCP joints to 50 degrees and DIP joints to 50 degrees. 5. Prior to November 21, 2011, the Veteran's hearing acuity was manifested by average pure tone thresholds at 1,000, 2,000, 3,000, and 4,000 hertz of 52.5 decibels in the right ear and 26.25 decibels in the left ear. Speech recognition ability was 94 percent correct in the right ear and 92 percent correct in the left ear. 6. Between November 21, 2011, and October 13, 2014, the Veteran's acuity was manifested by average pure tone thresholds at 1,000, 2,000, 3,000, and 4,000 hertz of 105 decibels in the right ear and 38.75 decibels in the left ear. Speech recognition ability was 0 percent correct in the right ear and 100 percent correct in the left ear. 7. As of October 14, 2014, the Veteran's hearing acuity was manifested by average pure tone thresholds at 1,000, 2,000, 3,000, and 4,000 hertz of 103 decibels in the right ear and 69 decibels in the left ear. Speech recognition ability was 4 percent correct in the right ear and 92 percent correct in the left ear. 8. Service connection is currently in effect for residuals of a puncture wound of the right hand with periarticular osteopenia and osteoarthritis, rated 50 percent disabling; bilateral hearing loss, rated 40 percent disabling; and tinnitus, rated 10 percent disabling. The Veteran's combined evaluation is 70 percent, since October 14, 2014. 9. The veteran reported that he had eight years of education and primary work experience in landscaping and as a laborer. 10. The service-connected disabilities, standing alone, are shown to be of such severity as to effectively preclude all forms of substantially gainful employment. CONCLUSIONS OF LAW 1. A low back disability was neither incurred in nor aggravated by service nor may arthritis of the low back be presumed to have been incurred or aggravated therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 2. A right shoulder or arm disability was neither incurred in nor aggravated by service nor may arthritis of the shoulder be presumed to have been incurred or aggravated therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015). 3. The criteria for an increased rating in excess of 10 percent for residuals of a puncture wound, right hand with periarticular osteopenia and osteoarthritis were not been met prior to November 23, 2011. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code (Code) 5215 (2015). 4. The criteria for an increased rating in excess of 50 percent for residuals of a puncture wound, right hand with periarticular osteopenia and osteoarthritis have not been met from November 23, 2011. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Code 5220 (2015). 5. The criteria for an initial compensable rating for bilateral hearing loss have not been met prior to November 21, 2011. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.85, Code 6100 (2015) 6. The criteria for an increased initial rating in excess of 10 percent for bilateral hearing loss were not met between November 21, 2011, and October 13, 2014. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.85, Code 6100 (2015) 7. The criteria for an increased initial rating in excess of 40 percent for bilateral hearing loss were not met from October 14, 2014, and thereafter. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.85, Code 6100 (2015) 8. The requirements for a total rating based on individual unemployability due to service-connected disabilities have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.340, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between a veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to the initial adjudication of the claims. A November 2006 letter explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. This letter also informed the Veteran of disability rating and effective date criteria. The Veteran has had ample opportunity to respond and supplement the record. Regarding the claim for an initial increased rating or ratings for hearing loss, as the rating decision on appeal granted service connection and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess 19 Vet. App. at 490. In a claim for increase such as that of the puncture wound of the right hand, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. The Veteran was afforded VA medical examinations, most recently in October and December 2014. The Board finds that the opinions obtained are adequate. The opinions were provided by qualified medical professionals and were predicated on a full reading of all available records. The examiners also provided a detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the representative has challenged the adequacy of the examination obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2015). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, as identified in 38 C.F.R. § 3.309(a), noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In order to prevail on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1990). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1990); 38 C.F.R. § 3.303(a). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2015). When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Lay statements may support a claim for service connection by establishing the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), they are not competent to provide opinions on medical issues that fall outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d 1372. Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Low Back The Veteran contends that service connection should be established for residuals of a low back injury that he sustained while in service. In correspondence, he stated that he injured the low back in the same incident in which he sustained his service-connected right hand injury. He has related that he has had five surgeries involving the low back since his discharge from service. After review of the record, the Board finds that a low back disability was not evident during service or until several years thereafter and is not shown to have been caused by any in-service event. In this regard, it is noted that there were no complaints or manifestations of a low back disability while the Veteran was on active duty. This includes no reference to a back injury, including at the time the Veteran sustained a puncture injury of the right hand during service. On examination for separation from active duty, clinical evaluation of the spine was normal. In 1976, the Veteran submitted a claim for VA pension, which was denied on the basis that he did not have sufficient wartime service. At that time, his claim was for disability from a back injury, noting two surgeries since 1967. His claim did not include a claim of compensation based on inservice incurrence of a low back disability. Post-service medical evidence includes treatment records dated in September 1973 that show that the Veteran was treated for a herniated lumbar disc. At that time, it was reported that the Veteran had had back problems since 1967. In a February 1976 statement, the Veteran's private physician indicated that he had been treating the Veteran for low back disability since 1969. He stated that the Veteran had had two previous operative procedures on the back and now continued to have severe chronic back pain. Private treatment records dated in March 2005 show that the Veteran was known to have ankylosing spondylitis and degenerative disk disease of the lumbosacral spine. VA outpatient treatment records show that the Veteran continued to receive treatment for complaints of chronic low back pain over the years. In a July 2014 report of private treatment, it was reported for clinical purposes that the Veteran had been diagnosed with ankylosing spondylosis with multiple level fusion surgeries in 1967, 1973, 1984, 1988, and 1991. The Veteran's back disability is shown to be diagnosed as ankylosing spondylosis, which is a form of rheumatoid arthritis. Dorland's Illustrated Medical Dictionary 1563 (28th ed. 1994). The disability is not shown to have been manifested during service and is not shown to have been the result of an inservice event. While the Veteran has contended that he sustained an injury of the back at the time he sustained the right hand injury for which service connection has been established, as noted, there is no indication in the Veteran's STRs that he sustained such an injury; the examination at separation from service showed his spine to be normal at that time; and he did not claim an inservice injury at the time of his pension claim in 1976. Moreover, records of treatment and clinical reports dated in 1973, 1976 and 2005 are conspicuously silent for any mention of a low back injury during service. The Board finds that if the appellant had, in fact, been suffering from residuals of a low back injury since service, he would have mentioned it at some time while he was seeking treatment for his back disabilities. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (holding that silence in a medical record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder (citing Fed. R. Evid. 803 (7))). For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for low back disability, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015). Right Shoulder or Arm Disability The Veteran contends that service connection should be established for a right shoulder or arm disability that he sustained while in service. In correspondence, he stated that he injured the arm and shoulder in the same incident in which he sustained his service-connected right hand injury. After review of the evidence of record, the Board finds that a right shoulder or arm disability was not evident during service or until many years thereafter and is not shown to have been caused by any in-service event. In this regard, it is noted that the Veteran's STRs show no complaint or manifestation of a right arm or shoulder disability. While the Veteran's right hand injury is documented, treatment records following the injury do not mention disability of the right arm or shoulder. On examination for separation from service, clinical evaluation of the upper extremities was normal. In his claim for pension benefits in 1976, the Veteran made no mention of a right arm or shoulder disorder and such a disability was not noted in the medical evidence submitted in connection with that pension claim. Neither are right arm or shoulder disabilities noted in the private treatment records dated from 1973 to 2005, which show only treatment for disabilities involving the low back, including sciatica. Private treatment records dated in March 2012 show that the Veteran received treatment at that time for complaints of right shoulder pain. At that time, it was reported that his pain had started the previous Friday after he was released from rehabilitation following a fall and given a pair of crutches. He stated that one hour after using the crutches, he was not able to use them due to increased pain. X-ray studies showed moderate osteoarthritis change of the right shoulder joint. An examination was conducted by VA in December 2014. At that time, the diagnoses were right shoulder degenerative joint disease with calcific tendinosis of the right rotator cuff and adhesive capsulitis. The examiner dated the diagnosis from 2009. The examiner reported that at the time he had punctured his right hand on a nail while in service in 1959, he stated that he had hit the wall hard and hurt his shoulder. He reported that he was seen in medical and his hand wound was bandaged and his arm placed in a sling, but could not recall any specific evaluation or treatment for the shoulder. He stated that he recovered and returned to duty in about a week. He reported that, following service, he worked in landscaping, doing heavy lifting. His shoulder pain worsened in the 1970's that was not associated with any particular injury or trauma. The Veteran had also been diagnosed with cervical radiculopathy and cervical myopathy involving the upper extremities and had had cervical surgery in February 2014, without improvement. Currently, he had decreased range of motion of the right shoulder, as well as mild decreases in the left. He stated that he was unable to lift his right arm much above the waist, and that the arm and shoulder felt numb and were very sensitive to touch. He reported chronic daily pain. Following examination and review of the medical records, the examiner, in December 2014 was asked to render an opinion regarding whether the current right arm or shoulder disability was related to the Veteran's active service, including whether it was causally related to the in-service fall in 1959. The examiner responded that it was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale was that the Veteran was currently identified as having significant medical conditions affecting the right upper extremity including residuals of a puncture wound of the right hand with osteoarthritis of the right thumb, chronic right cervical radiculopathy with cervical myelopathy and complex regional pain syndrome, right median nerve neuropathy, history of right wrist ganglion cyst, and right shoulder degenerative joint disease with calcific tendinosis, right rotator cuff, and adhesive capsulitis. The examiner stated that, other than the service-connected right hand condition, the remaining conditions identified were not related to the right hand condition or the in-service injury in 1959. In support of this conclusion, the examiner gave numerous reasons. It was stated that there was no evidence to support an ongoing or chronic disability pattern related to the right upper extremity as a result of the in-service injury during the remainder of the Veteran's service. Significant shoulder, wrist or arm injury at the time of this incident would be expected to affect ability to perform service duties, which the Veteran was able to continue to perform for the duration of service. At the time of discharge from service the Veteran did not identify ongoing upper extremity pain or other condition. Following discharge from service, the Veteran worked in jobs requiring heavy physical labor and it would be expected that if he had significant upper extremity injury or ongoing disability condition it would have severely affected his ability to perform this work. At the time that the Veteran went on Social Security Disability following a back injury in 1967, there was no mention of any upper extremity condition. The first historic evidence of right upper extremity symptoms were recorded in 1985 where the diagnosis was "Radiculopathy right arm, right diabetic neuropathy". This actually supports a conclusion that there was no connection between the Veteran's subjective symptoms at the time and the in-service injury. Radiculopathy in reference to the upper extremity means it was suspected the Veteran's symptoms were due to cervical spine disease/peripheral nerve condition rather than due to intrinsic shoulder or arm condition. There is no evidence the Veteran had a neck injury associated with the in-service injury and there is no evidence that the Veteran had nerve damage associated with the in-service injury. The Veteran had no complaints of neck pain or numbness or tingling at the time of presentation and additionally the mechanism of injury would not be expected to result in these conditions. The Veteran had no neck injury in service and his neck condition initially identified in 1985 as radiculopathy is the primary source of his ongoing symptoms and disability of the right upper extremity. The cervical condition progressed with chronic cervical radiculopathy, cervical myopathy requiring cervical surgery with a complex regional pain syndrome all related to the cervical disease. This affected his hand, wrist, arm and shoulder and was the primary etiology of his upper extremity disability and symptoms. The Veteran had an additional diagnosis of median nerve neuropathy of right hand that likely contributed to pain, weakness and numbness of the wrist and hand, without evidence of median nerve neuropathy associated with the in-service injury. The Veteran had a current diagnosis of rotator cuff tendosis and adhesive capsulitis of the right shoulder along with DJD. There is no evidence of significant shoulder injury with the in-service injury. An injury causing rotator cuff tear or strain would have been expected to cause significant ongoing symptoms and disability and an injury that would be significant enough to result in traumatic DJD would also be expected to have significant acute symptoms which would not be expected to resolve in the time noted for recovery for this in-service injury. In addition given the post service labor the Veteran performed it is not likely he did so with a rotator cuff condition or chronic shoulder condition. In addition, any condition that was initiated in 1959 would have been expected to worsen or have significant disability by the time of the 1967 disability evaluation, but no such condition was identified at the time. With regards to the arthritis, there was no evidence that the Veteran developed early DJD as a result of trauma given the initial diagnosis of DJD in 2012 with bone scan in 2010 showing no shoulder uptake. The shoulder DJD is not an unexpected finding given the Veteran's age and diffuse DJD of other joints. The Veteran reported multiple medical visits in his post service years for injuries with mechanisms of action that could be expected to result in rotator cuff injury or eventual DJD and additionally worked for years in physical labor jobs that increased his risk for eventual DJD. The adhesive capsulitis was also identified in 2012 and was likely due to his decreased use of the arm and shoulder due to the radiculopathy, myopathy and resulting pain as the orthopedic specialist did not think the small amount of arthritis present could be causing the symptoms. Remote history of trauma is not identified as a cause of this condition in the medical literature. In summary, the examiner stated that there was no support that the Veteran had early DJD as a result of in-service injury as his DJD was identified many years later, is relatively mild and is associated with DJD in multiple other joints suggesting genetic and age-related causes. In summary, the Veteran had a minor injury involving puncture wound to right hand in service with no evidence of ongoing right upper extremity disability following the short recovery. He did not have conditions that were considered long term results of the injury. Given the evidence of record, the Board can find no basis for the establishment of service connection for a right shoulder or arm disability. The Veteran did not manifest the disability in service, including at the time of the injury of his right hand in service. He did not manifest a right shoulder disability, including arthritis, until many years after service and is not shown by the evidence to have had complaints of right shoulder pain continuously since his discharge from active duty. The only medical opinion in the record does not support a finding that any of his current right shoulder disabilities are related to service, including an injury at the time he sustained the wound of his right hand. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a right shoulder or arm disability, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Increased Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2015). Where there is a question as to which of two evaluations shall be applied, the higher rating 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. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2015). In this case, the Board has considered the entire period of initial rating claim from the effective date of service connection to see if the evidence warrants the assignment of different ratings for different periods of time during these claims, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The United States Court of Appeals for Veterans Claims (Court) has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the function affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. More generally, disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In addition, the intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. This regulation also provides that the intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and that crepitation should be noted carefully as points of contact which are diseased. Thus, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The Court has also held that VA's regulations pertaining to whether a compensable rating is warranted for pain (as shown by adequate pathology and evidenced by the visible behavior in undertaking motion), 38 C.F.R. §§ 4.40 and 4.59, apply regardless of whether the painful motion is related to arthritis. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Right Hand Disability Service connection for a puncture wound of the right hand was granted by the RO in a January 1983 rating decision. A noncompensable (0 percent) initial disability rating was awarded under the provisions of Code 7805, as a non-tender scar. The rating was increased to 10 percent in a December 2007 rating decision as analogous to wrist limitation of motion under Code 5215. The rating was further increased to 50 percent, effective November 23, 2011, under Code 5220, as analogous to favorable ankylosis of all five digits of the right hand. An examination was conducted by VA in December 2006. At that time, it was reported that he had fallen while in service and, when he put his hand out to brace himself, he put his hand on an exposed nail sustaining a puncture wound to the thenar area of the hand. Currently, he reported pain in the right wrist, especially on the dorsum of the wrist, which decreased strength in the hand as well as range of motion. On examination, there were well-healed scars dorsally over the radiocarpal joint. There was tenderness to palpation with bony prominence evident on inspection as well as palpation in the dorsal radial area of the right wrist. There was no significant increased warmth. Range of motion was dorsiflexion from 0 to 40 degrees and palmar flexion was from 0 to 50 degrees. There was 20 degrees of ulnar deviation and 20 degrees of radial deviation. Range of motion was limited at the extremes by pain, not weakness, fatigability or lack of endurance with repetitive use. Range of motion of the MCP joint was from 0 to 90 degrees, the PIP joint range was from 0 to 100 degrees and the DIP joint was from 0 to 70 degrees. There was no limitation of the joint movement by pain, weakness, fatigability, or lack of endurance on repetitive use. Strength was 5/5 for wrist flexion and wrist dorsiflexion. The diagnosis was right wrist pain. An examination was conducted by VA on November 23, 2011. At that time, it was noted that the Veteran's right hand was dominant. On examination of the right wrist, there was tenderness, but no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, drainage or subluxation. Dorsiflexion of the right wrist was to 40 degrees, palmar flexion was to 50 degrees, radial deviation was to 5 degrees and ulnar deviation was to 30 degrees. On the right, the joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The right hand examination revealed a decrease in strength in regards to pulling, pushing and twisting. On examination of the right thumb or fingers there was no ankylosis. On examination of right hand dexterity with the thumb attempting to oppose the fingers, there was no gap between the thumb pad and the right index fingertip. There was objective evidence of thumb pain on this attempt. After 3 repetitions, there was objective evidence of thumb pain. There was no new or additional limitation of the thumb on repetitive motion. After repetitive use, the motion of the right thumb to the right index finger was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination. On examination of the right index finger, range of motion of the right index finger was PIP to 90 degrees, MCP to 50 degrees, and DIP to 50 degrees. Range of motion of the long finger was PIP to 90 degrees, MCP to 50 degrees, and DIP to 50 degrees. Range of motion of the ring finger was PIP to 90 degrees, MCP to 50 degrees and DIP to 50 degrees. Range of motion of the little finger was PIP to 90 degrees, MCP to 50 degrees, and DIP to 50 degrees. On the right, the joint function is not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The clinical findings of the right wrist and fingers were considered to be consistent with the Veteran's cervical disc disease and ankylosing spondylitis, not with the puncture wound. X-ray studies showed periarticular osteopenia and osteoarthritis. The diagnosis was status post puncture wound of the right hand with periarticular osteopenia and osteoarthritis. The subjective factors were pain, stiffness, decreased strength, decreased flexibility and locking in the thumb and wrist. There were no visible scars from the wound. An examination was conducted by VA in December 2014. At that time, the Veteran stated that his whole hand was in pain constantly. The pain extended from the hand to the wrist and forearm. He reported decreased grasp strength and decreased ability for small tasks such as picking up small objects. He stated that he sometimes dropped things. Pain was increased with cold weather and repetitive movement such as using tools. The Veteran reported that when he had increased pain due to weather or activities it lasted at least one day and often several days. This could occur 1-2 times a week. In addition to difficulty using tools, the Veteran reported he had difficulty with prolonged writing. He was able to button his own buttons and perform activities of daily living. There was limitation of motion of all of the digits of the right hand. There was no gap between the thumb pad and fingers, but there was a gap between the fingertips and the proximal transverse crease of the palm and painful motion in attempting to touch the palm with the fingertips. There was a gap of less than one inch of the little finger. The examiner clarified that the gap was only for right little finger; however the Veteran had pain with range of motion of all fingers and the thumb when tips were within less than one inch There was no additional limitation of motion after repetitive use testing. The examiner did note less movement than normal on the right, weakened movement, and pain on movement. There was tenderness to palpation of the joints of the hand. Grip strength was 4/5. There was no ankylosis of the thumb or fingers. X-ray studies showed arthritis of the hand. As noted, the 10 percent rating that became effective for the period prior to November 23, 2011, was based upon limitation of motion of the Veteran's wrist. Normal ranges of motion of the wrist are dorsiflexion from 0 degrees to 70 degrees, and palmar flexion from 0 degrees to 80 degrees. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5214 provides ratings for ankylosis of the wrist. Favorable ankylosis of the wrist in 20 degrees to 30 degrees dorsiflexion is rated 30 percent disabling for the major wrist and 20 percent for the minor wrist; ankylosis of the wrist in any other position except favorable is rated 40 percent disabling for the major wrist and 30 percent for the minor wrist; and unfavorable ankylosis of the wrist in any degree of palmar flexion, or with ulnar or radial deviation, is rated 50 percent disabling for the major wrist and 40 percent for the minor wrist. 38 C.F.R. § 4.71a. A Note provides that extremely unfavorable ankylosis will be rated as loss of use of hand under Diagnostic Code 5125. 38 C.F.R. § 4.71a. Diagnostic Code 5215 provides ratings based on limitation of motion of the wrist. Limitation of palmar flexion in line with the forearm is rated 10 percent disabling for the major wrist and 10 percent for the minor wrist; limitation of dorsiflexion to less than 15 degrees is rated 10 percent disabling for the major wrist and 10 percent for the minor wrist. 38 C.F.R. § 4.71a. As of November 23, 2011, the Veteran's right hand disability was rated as analogous to favorable ankylosis of the right hand. The diagnostic codes that focus on ankylosis or limitation of motion of single or multiple digits of the hand are found at 38 C.F.R. § 4.71a, Codes 5216 to 5230. According to Note (1) of the "Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand" Table in 38 C.F.R. § 4.71a, for digits II through V, the MCP joint has a range of motion of zero to 90 degrees of flexion, the PIP joint has a range of motion of zero to 100 degrees of flexion, and the DIP joint has a range of motion of zero to 70 or 80 degrees of flexion. For the index, long, ring, and little fingers (digits II, III, IV, and V), zero degrees of flexion represents the fingers fully extended, making a straight line with the rest of the hand. The position of function of the hand is with the wrist dorsiflexed 20 to 30 degrees, the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints flexed to 30 degrees, and the thumb (digit I) abducted and rotated so that the thumb pad faces the finger pads. Only joints in these positions are considered to be in favorable position. See 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note (1). When two or more digits of the same hand are affected by any combination of amputation, ankylosis, or limitation of motion that is not otherwise specified in the rating schedule, the evaluation level assigned will be that which best represents the overall disability (i.e., amputation, unfavorable or favorable ankylosis, or limitation of motion), assigning the higher level of evaluation when the level of disability is equally balanced between one level and the next higher level. See 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note (2). Evaluation of ankylosis of the index, long, ring, and little fingers: (i) If both the MCP and PIP joints of a digit are ankylosed, and either is in extension or full flexion, or there is rotation or angulation of a bone, evaluate as amputation without metacarpal resection, at proximal interphalangeal joint or proximal thereto; (ii) If both the MCP and PIP joints of a digit are ankylosed, evaluate as unfavorable ankylosis, even if each joint is individually fixed in a favorable position; (iii) If only the MCP or PIP joint is ankylosed, and there is a gap of more than two inches (5.1 cm.) between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible, evaluate as unfavorable ankylosis; and (iv) If only the MCP or PIP is ankylosed, and there is a gap of two inches (5.1 cm.) or less between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible, evaluate as favorable ankylosis. See 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note (3). If there is limitation of motion of two or more digits, evaluate each digit separately and combine the evaluations. See 38 C.F.R. § 4.71a, Evaluation of Ankylosis or Limitation of Motion of Single or Multiple Digits of the Hand, Note (5). Examination prior to November 2011 shows that the Veteran had wrist range of motion from 0 to 40 degrees of dorsiflexion and 0 to 50 degrees of palmar flexion. While this limitation of motion is sufficient to warrant a 10 percent rating under limitation of motion of the wrist, for a rating in excess of 10 percent, some ankylosis of the wrist or limitation of the individual fingers would have to be demonstrated. The examination of record does not demonstrate ankylosis of the wrist and range of motion of the fingers of the right hand was shown to be from 0 to 90 degrees at the MCP, from 0 to 100 degrees at the PIP joint and from 0 to 70 degrees at the DIP. There was no limitation of the joint movement by pain, weakness, fatigability, or lack of endurance on repetitive use. Under these circumstances, there is no basis for a rating in excess of 10 percent prior to November 23, 2011. Regarding a rating in excess of 50 percent from November 23, 2011, the Veteran's right hand limitation of motion of individual digits are not shown to be compensable under Codes 5228, 5229, and 5230, as the Veteran, on examination, was able to achieve gaps of less than one inch with all fingers throughout the appeal period from this date. The other Codes related to the fingers and thumb have maximum ratings that are less than or equal to the Veteran's current 50 percent rating (Codes 5219, 5222, 5223, 5224, 5225, 5226, 5227). Therefore, these Codes are not applicable and will not be discussed further. In order to warrant a rating in excess of 50 percent for a disability in the dominant hand, the evidence must show unfavorable ankylosis of five digits of one hand (60 percent under Diagnostic Code 5216); or unfavorable ankylosis of the thumb and three fingers under Diagnostic Code 5217). It is noted that the record does not indicate and the Veteran has not alleged that he suffers from ankylosis of any of the digits of his right hand. As unfavorable ankylosis has not been demonstrated, a rating in excess of 50 percent as analogous to favorable ankylosis is not shown to be warranted at any time throughout the appeal. The Board also has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2015); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. In this case, comparing the Veteran's disability level and symptomatology to the rating schedule, the degree of disability throughout the appeal period under consideration is contemplated by the rating schedule. The Veteran's right hand limitation of wrist motion directly corresponds to the schedular criteria for the 10 percent evaluation (Code 5215), which also incorporates various orthopedic factors that limit motion or function of the wrist. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. It is significant that no additional limitation of the hand was demonstrated prior to November 23, 2011. From this date, the right hand impairment manifested by limitation of motion of the thumb and fingers of the right hand is rated by analogy to favorable ankylosis of the five digits of the hand (Code 5220) and more nearly approximates the disability specifically contemplated in the schedular rating criteria for arthritis with limitation of motion. For this reason, the Board finds that the assigned schedular ratings are adequate to rate the Veteran's right hand disability, and no referral for an extraschedular rating is required. Bilateral Hearing Loss For evaluation of hearing impairment, examinations are conducted using the controlled speech discrimination test together with the results of pure tone audiometry testing. A numeric designation of impaired efficiency is then assigned based upon the results of these tests and a percentage evaluation is reached by correlating the results for each ear. 38 C.F.R. § 4.85 and Tables VI, VIa, and VII. When the puretone threshold at each of the four specified frequencies is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table Via, whichever results in the higher numeral. Each ear will be evaluated separately. When the puretone threshold is 30 decibels or less at 1000 hertz, and 70 decibels or more at 2000 hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table Via, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86. An audiometric evaluation was conducted for compensation purposes for the VA in March 2007. At that time, the veteran's organic hearing acuity shown to be as follows: Hertz 1000 2000 3000 4000 Right ear 45 50 55 60 Left ear 15 15 35 40 Thus, his acuity was manifested by average pure tone thresholds at 1,000, 2,000, 3,000, and 4,000 hertz of 52.5 decibels in the right ear and 26.25 decibels in the left ear. Speech recognition ability 94 percent correct in the right ear and 92 percent correct in the left ear. An audiometric evaluation was conducted for compensation purposes for the VA on November 21, 2011. At that time, the veteran's organic hearing acuity shown to be as follows: Hertz 1000 2000 3000 4000 Right ear 105 105 105 105 Left ear 25 20 50 60 Thus, his acuity was manifested by average pure tone thresholds at 1,000, 2,000, 3,000, and 4,000 hertz of 105 decibels in the right ear and 38.75 decibels in the left ear. Speech recognition ability 0 percent correct in the right ear and 100 percent correct in the left ear. An audiometric evaluation was conducted for compensation purposes for the VA on October 14, 2014. At that time, the veteran's organic hearing acuity shown to be as follows: Hertz 1000 2000 3000 4000 Right ear 105 105 100 100 Left ear 65 65 75 70 Thus, his acuity was manifested by average pure tone thresholds at 1,000, 2,000, 3,000, and 4,000 hertz of 103 decibels in the right ear and 69 decibels in the left ear. Speech recognition ability 4 percent correct in the right ear and 92 percent correct in the left ear. The assignment of a disability rating for hearing impairment is derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). In the instant case, the application of the rating schedule to the pertinent facts demonstrates that a compensable evaluation is not warranted for a bilateral hearing loss prior to November 21, 2011, when hearing acuity warranting a 10 percent rating is demonstrated. Neither is a rating in excess of 40 percent demonstrated prior to October 14, 2014. The Board has considered the application of 38 C.F.R. § 4.86(a), where applicable. The Board notes that, in Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007), the Court held that, relevant to VA audiological examinations, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. In this regard, the examiner in October 2014 specifically noted the Veteran's hearing disability would likely interfere with any form of employment requiring critical communication skills such as a 911 operator, but he might be suitable for other less communication-intensive forms of employment if he were to wear appropriate binaural amplification. The Board notes that the Court's rationale in requiring an examiner to consider the functional effects of a veteran's hearing loss disability involves the potential application of 38 C.F.R. § 3.321(b) in considering whether referral for an extra-schedular rating is warranted. Specifically, the Court noted that, "[u]nlike the rating schedule for hearing loss, 38 C.F.R. § 3.321(b) does not rely exclusively on objective test results to determine whether a referral for an extraschedular rating is warranted. The Secretary's policy requiring VA audiologists to describe the effect of a hearing disability on a Veteran's occupational functioning and daily activities facilitates such determinations by requiring VA audiologists to provide information in anticipation of its possible application." Martinak, 21 Vet. App. at 455. Under 38 C.F.R § 3.321(b)(1), in exceptional cases where schedular evaluations are found to be inadequate, consideration of an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities is made. The governing norm in an exceptional case is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See 38 C.F.R § 3.321(b)(1) (2015). In this case, the Schedule is not inadequate. The Schedule does provide for higher ratings for the service-connected hearing loss. Moreover, as discussed above, the schedular criteria for higher ratings have not been shown. While the Board recognizes and has considered the Veteran's complaints of difficulty in hearing associated with his service-connected hearing loss, the Board notes that even the schedular rating criteria provide for ratings based on exceptional hearing patterns, which are not demonstrated in this case. In addition, the record reflects that the Veteran has not required frequent hospitalizations for his hearing loss. Further, there is no indication that the hearing loss alone significantly interferes with employment, although this aspect of the Veteran's disability will be more fully described in the discussion relating to TDIU. In sum, there is no indication in the record that the average industrial impairment from the hearing loss disability would be in excess of that contemplated by the assigned schedular ratings. For these reasons, referral for an extra-schedular rating is not warranted. TDIU Total disability ratings for compensation 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. When these percentage standards are not met, consideration may be given to entitlement on an extraschedular basis, taking into account such factors as the extent of service-connected disability, and employment and educational background. It must be shown that service-connected disability produces unemployability without regard to advancing age. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16, 4.19. Marginal employment shall not be considered substantially gainful employment. Marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the United States Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts found basis (included but not limited to employment in a protected environment such as a family business or sheltered workshop) when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16. Service connection is currently in effect for residuals of a puncture wound of the right hand with periarticular osteopenia and osteoarthritis, rated 50 percent disabling; bilateral hearing loss, rated 40 percent disabling; and tinnitus, rated 10 percent disabling. The Veteran's combined evaluation is 70 percent, since October 14, 2014. In his application for TDIU, the Veteran reported that he had 8 years of education and additional education in drafting. He reported work experience in landscaping and as a laborer. He also reported working in mechanical drafting, but only for two months in 1969. He stated that he last worked in 1969 as a landscaper. For a veteran to prevail on a claim for TDIU, the record must reflect some factor which takes his case outside of the norm. The sole fact that he 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 and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). As noted, the VA examination in October 2014 included an opinion regarding the Veteran's potential for employability. The examiner stated that the Veteran's hearing loss made him unsuitable for any form of employment requiring critical communication skills such as a 911 operator, but that he might be suitable for other less communication-intensive forms of employment if he wore appropriate binaural amplification. On VA examination in December 2014 the examiner rendered an opinion that the Veteran has limitations for physical employment based on his right hand disability in that he was shown to be unable to perform tasks requiring prolonged or repetitive turning of the wrist or repetitive grasping such as in activities involving hand tools, repetitive lifting and carrying more than 5 pounds and repetitive pushing and pulling activities. The Veteran's right hand is his dominant hand. This examiner also noted that the Veteran had limitations for sedentary employment in that he could not perform repetitive hand writing tasks. Thus the Veteran's service-connected disabilities are shown to interfere with both physical and sedentary employment. The Board is cognizant of the numerous other disabilities with which the Veteran must contend. These include bilateral blindness, diabetes mellitus, and ankylosing spondylosis. The Board finds, however, that the Veteran's service-connected disabilities, standing alone, are sufficient to render him unable to obtain or retain substantially gainful employment. This is particularly true in light of his eighth grade education and work experience that primarily involved manual labor. Thus, resolving reasonable doubt in the Veteran's favor, TDIU is granted. ORDER Service connection for a low back disorder is denied. Service connection for a sprain of the right upper extremity, claimed as a shoulder and arm disorder, is denied. An increased rating for residuals of a puncture wound, right hand with periarticular osteopenia and osteoarthritis, in excess of 10 percent prior to November 23, 2011, and 50 percent therefrom, is denied. An increased rating for bilateral hearing loss, initially rated noncompensable prior to November 21, 2011, 10 percent from November 21, 2011, to October 13, 2014, and 40 percent thereafter, is denied. TDIU is granted, subject to controlling regulations applicable to the payment of monetary benefits. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs