Citation Nr: 1801606 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 14-13 450 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for right adductor magnus, longus, and brevis muscle strain and tendonitis at the insertions upon the posterior and inferior pubic rami ("right groin disability"). 2. Entitlement to an initial disability rating in excess of 10 percent for left adductor magnus, longus, and brevis muscle strain and tendonitis at the insertions upon the posterior and inferior pubic rami ("left groin disability"). 3. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU). ORDER A 20 percent disability rating for right adductor magnus, longus, and brevis muscle strain and tendonitis at the insertions upon the posterior and inferior pubic rami is granted for the entire initial rating period on appeal. A 20 percent disability rating for left adductor magnus, longus, and brevis muscle strain and tendonitis at the insertions upon the posterior and inferior pubic rami is granted for the entire initial rating period on appeal. A TDIU is denied prior to June 16, 2017. A TDIU is granted from June 16, 2017. FINDINGS OF FACT 1. Throughout the initial rating period, the Veteran's bilateral groin disabilities have manifested constant pain requiring the use of a jock strap and a cane to ambulate and resulting in periods when he has to lay down; flexion has been limited to no worse than 60 degrees, extension limited to 5 degrees, and abduction limited to 20 degrees, and adduction has not been limited such that the Veteran cannot cross his legs, nor has rotation been limited such that he cannot toe-out more than 15 degrees. 2. Prior to June 16, 2017, the Veteran had a combined disability rating of 40 percent; referral for consideration of an extra-schedular TDIU. 3. From June 16, 2017, the Veteran had a combined disability rating of 80 percent with one disability rated as 70 percent disabling, and he was rendered unable to obtain or maintain substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for a 20 percent disability rating for right adductor magnus, longus, and brevis muscle strain and tendonitis at the insertions upon the posterior and inferior pubic rami have been met for the entire initial rating period on appeal. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.56, 4.59, 4.71a, Diagnostic Code (DC) 5253 (2017). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for a 20 percent disability rating for left adductor magnus, longus, and brevis muscle strain and tendonitis at the insertions upon the posterior and inferior pubic rami have been met for the entire initial rating period on appeal. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.56, 4.59, 4.71a, Diagnostic Code (DC) 5253 (2017). 3. Prior to June 16, 2017, the schedular criteria for a TDIU were not met; and referral for extraschedular . 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16, 4.18, 4.19 (2017). 4. Resolving reasonable doubt in the Veteran's favor, the criteria for a TDIU have been met from June 16, 2017. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16, 4.18, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant in this case, had active service from March 1985 to March 1988. This matter comes before the Board of Veterans' Appeals (BVA or Board) from an August 2011 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The Veteran and his wife provided testimony at a June 2017 Travel Board hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is associated with the claims folder. The issue of TDIU has been raised during the adjudicatory process of the underlying disabilities. As such, it is part and parcel of the claim for benefits for the underlying disabilities. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Initial Ratings for Groin Disabilities Service connection for right and left adductor magnus, longus, and brevis muscle strain and tendonitis at the insertions upon the posterior and inferior pubic rami was granted in the August 2011 rating decision that is the subject of this appeal. Initial 10 percent disability ratings were assigned, effective from July 26, 2010, under the provisions of 38 C.F.R. § 4.71a, DC 5253. The Veteran contends that he is entitled to higher initial disability ratings for his bilateral groin disabilities. Specifically, he has stated that he suffers from severe pain, and that this pain limits his ability to engage in activities such as bicycle riding, being intimate with his wife, and participating in activities with his daughter. Further, he states that he has to lie in bed on many occasions due to his pain, and that the range of motion of his hips is severely limited and painful. Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. at 469; 38 C.F.R. § 3.159(a)(2). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of a veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In this case, as noted above, the Veteran is in receipt of 10 percent disability ratings for his right and left groin disabilities throughout the entire initial rating period on appeal, under the provisions of 38 C.F.R. § 4.71a, DC 5253. Under DC 5253, which contemplates impairment of the thigh, a 10 percent evaluation is warranted when there is limitation of rotation of the thigh such that the Veteran cannot toe-out more than 15 degrees, or when there is limitation of adduction such that the Veteran cannot cross his legs. 38 C.F.R. § 4.71a. A 20 percent evaluation is warranted when there is limitation of abduction such that motion is lost beyond 10 degrees. Id. Turning to the evidence relevant to the initial rating period, in an August 2010 Statement in Support of Claim, the Veteran stated that he could not jump up and down without pain, that he wears a support to keep his testicles from moving, and that at the end of the day, his wife had to rub them very lightly to alleviate the pain. His wife also submitted a statement in August 2010, in which she stated that he could not lift heavy objects or jump, and that his testicles were very sensitive to touch. Further, she confirmed that he wears a jock strap daily for support, and stated that he had to leave his job because of his groin disabilities. Finally, she stated that he sometimes lay in bed not wanting to walk because of the pain. The Veteran was afforded a VA examination in December 2010. He reported worsening complaints of groin discomfort as well as testicular discomfort, noting that with any type of heavy exertion or pushing anything, for the next several days, he experienced extreme right groin discomfort and was essentially incapacitated because of the pain. He stated that he also had difficulty walking in a normal way as he could not fully bear weight on his right leg due to pain. He reported using heating pads periodically to relieve the discomfort, but did not note any specific complaints of muscle spasm. He also reported limitation in his occupation, stating that he could no longer work as a truck driver because of constant groin discomfort. He also noted limitations of his activities of daily living as he was not able to walk for lengthy periods of time and also has some impairment of sexual intercourse with his wife, not because of any erectile problems, but because of discomfort in his leg and groin area. Genitourinary exam was very limited due to the Veteran's extreme sensitivity to touch in his right groin and testicular area, but there was no obvious penile deformity and no evidence of testicular atrophy. The right groin was soft but very tender to palpation and the Veteran asked that his testicle specifically not be examined because of severe tenderness to palpation. The diagnosis was chronic right groin strain with associated testicular tenderness. The Veteran was afforded a VA muscle examination in June 2011. He described pain in the medial aspects of proximal thighs which was progressively worse. He stated that NSAIDS had not provided relief. He reported flare-ups occurring weekly, lasting one to two days, moderate in severity; precipitating factors were walking more than 100 yards, or climbing stairs or ladders. According to the Veteran, these flare-ups resulted in reduced ranges of motion of the hips by an additional 10 percent. On examination, it was noted that muscle function was not normal. There was pain and tenderness at the bilateral adductor tendon insertions on the posterior pubic rami. The Veteran reported that he retired from his job as a truck driver in June 2010 because of pain. The VA examiner diagnosed bilateral adductor magnus longus and brevis muscle strain and tendonitis at the insertions upon the posterior pubic rami, noting that the disability would result in decreased ranges of motion of the bilateral hips and referred pain to the bilateral genitalia. Moreover, the disability would have significant occupational effects, resulting in decreased mobility and problems with lifting and carrying, such that he could need to be assigned different duties and would have increased absenteeism. With regard to activities of daily living, the examiner noted that the bilateral groin disabilities would prevent exercise, sports, and recreation, would have moderate effects on chores, mild effects on traveling, and no effects on feeding, bathing, dressing, toileting, and grooming. The examiner also explained that adductor tendon insertional pain is poorly localized and is often referred to as genital pain, inguinal pain, and groin pain. The Veteran was also afforded a VA joints examination in June 2011. He reported that he was able to stand 3 to 8 hours with only short rest periods, and was able to walk 1 to 3 miles. He stated that he did not use any assistive devices. Gait was antalgic. On physical examination, there was tenderness at the adductor tendon insertions on the posterior pubic rami. Unless otherwise documented in the report no objective evidence of pain on ROM was noted, passive ROM was unchanged from active ROM, and on repetitive testing, range of motion values were unchanged from baseline values reported, and no pain, fatigue, weakness, or incoordination was noted. Active flexion was from 0 to 80 degrees with pain at 60 degrees. Passive flexion was from 0 to 90 degrees with pain at 60 degrees. Following repetitive use, the Veteran could not perform squats due to adductor insertional pain. Active extension was from 0 to 10 degrees with pain at 5 degrees. Passive flexion was from 0 to 15 degrees with pain at 5 degrees pain. Active abduction was from 0 to 30 degrees with pain at 20 degrees. Passive abduction was from 0 to 40 degrees with pain at 20 degrees. Active adduction was from 0 to 10 degrees with pain at 5 degrees. Passive adduction was from 0 to 15 degrees with pain at 5 degrees. Active internal rotation was from 0 to 20 degrees with pain at 10 degrees. Passive internal rotation was from 0 to 20 degrees with pain at 10 degrees. Active external rotation was from 0 to 30 degrees with pain at 10 degrees. Passive external rotation was from 0 to 30 degrees with pain at 10 degrees. The Veteran was able to cross his legs, and could toe out greater than 15 degrees. X-rays of the hips revealed no evidence of fracture or dislocation; joint space and soft tissue were within normal limits. The examiner diagnosed bilateral adductor muscle insertional tendonitis at the inferior pubic rami, noting that the Veteran would have pain from sitting on hard surfaces, decreased strength, and lower extremity pain. However, the examiner stated that the groin disabilities would have no effects on daily activities. Finally, the Veteran was afforded a VA genitourinary examination in June 2011. However, the examiner noted that genitourinary examination was completely normal, including the testicles and epididymis. There was no residual of right epididymitis, which in any case, was not caused by or the result of military service. Further, the examiner stated that there were no genitourinary conditions attributable to military service, noting that adductor tendonitis insertional pain is often misinterpreted by patients as having genitourinary causes. In his July 2012 notice of disagreement (NOD), the Veteran stated that he could not drive trucks because the bouncing of the truck and climbing in and out of the truck caused him pain. He also stated that, in the past, he had bad days and better days, but that currently, he only had bad days. He stated that he experienced pain every day and every night, when he laid down and stretched his leg out a certain way. He had to put ice on it and heat it for relief. Further, he stated that during his VA examinations, he was in severe pain when the examiner was bending and turning his legs during range of motion testing. A September 2014 VA treatment note indicates that genitourinary examination was normal, but that on musculoskeletal examination, the Veteran resisted movement of the hips. His gait was coordinated and smooth. There were no defects or deformities of the joints, bones, or muscles. Joints had range of motion within full limits with no pain or contractures. There was no muscle atrophy or weakness. At the June 2017 Board hearing, the Veteran testified that he had difficulty walking and sitting due to pain, and that he constantly used a cane to walk. Further, he stated that he could not ride a bike, roller skate, attend sports games, swim, or be intimate with his wife. A July 2017 VA treatment note indicates that the Veteran used ice/heat, wore a jock strap, and walked with a cane. He stated that he had to shift position frequently in the bed to alleviate pain. The pain was worse with palpation or movement. On musculoskeletal examination, there was no joint swelling, warmth, erythema, or loss of range of motion. However, the clinician noted that the Veteran would not allow range of motion testing of his hips as this made his pain worse. The clinician noted marked hyperalgesia of the suprapubic, bilateral inguinal, and bilateral upper inner thigh regions limiting examination (although inspection was unremarkable). For the reasons discussed below, although the criteria for disability ratings in excess of 10 percent are not met under DC 5253, in light of the Veteran's report of constant pain requiring the use of a jock strap and a cane and often causing him to lay down due to his pain, as well as his description of functional limitations, the Board has resolved any doubt in his favor and finds that 20 percent disability ratings are warranted for both the right and left groin disabilities for the entire initial rating period on appeal. As noted above, the criteria for higher ratings under DC 5253 are not met in this case without consideration of pain or functional loss. For instance, the evidence of record does not show that the Veteran has ever been unable to cross his legs or toe-out more than 15 degrees, or that his abduction was lost beyond 10 degrees, as specifically noted by the June 2011 VA joints examiner. Abduction, at worse, has been limited to 20 degrees, even with pain and after repetition, and with consideration that motion is limited at the point where pain sets in. However, in light of the Veteran's report of pain and functional limitations, the Board finds that his disability picture more closely approximates 20 percent ratings for both the right and left groin disability. The Board has considered whether any other diagnostic codes would allow for disability ratings even higher than 20 percent. However, the Veteran does not have ankylosis of either hip; therefore, DC 5250 does not apply. DC 5251 only allows for a 10 percent disability rating, at most. Flexion, at worst, was limited to 60 degrees, even with pain and after repetition, and with consideration that motion is limited at the point where pain sets in; therefore, DC 5252 does not provide for higher evaluations. He does not have flail joint or impairment of the femur, so DCs 5254 and 5255 are not applicable. 38 C.F.R. § 4.71a. The Board has also considered DC 5315, which contemplates disability of muscle group XV. This group of muscles affects adduction of the hip, flexion of the hip, and flexion of the knee, and includes the adductor longus, adductor brevis, adductor magnus, and gracilis. DC 5315 provides for a noncompensable rating when the disability is slight, 10 percent when it is moderate, 20 percent when it is moderately severe, and 30 percent when it is severe. 38 C.F.R. § 4.73. However, the Board finds that this diagnostic code is not applicable, as it generally applies to residuals of bullet, shell, shrapnel, or missile wounds. 38 C.F.R. § 4.56. Moreover, even if it did apply, the criteria for a rating in excess of 20 percent are not met under DC 5315, as the evidence does not demonstrate any of the criteria of a severe muscle disability listed under 38 C.F.R. § 4.56, including but not limited to scars, loss of muscle substance, swelling and hardening of muscles, severe impairment of function due to lack of strength, endurance, or coordinated movements, or muscle atrophy. The Board has considered the Veteran's statements regarding the severity of his bilateral groin disabilities. Certainly, as a lay person, the Veteran is competent to attest to physical symptoms that he experiences, such as pain. His statements describing his symptoms are considered to be competent evidence. King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Layno. These statements, however, must be viewed in conjunction with the medical evidence as required by the rating criteria. The Veteran is not competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's groin disabilities has been provided by the medical personnel who examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective complaints of increased symptomatology. Despite the Veteran's contention of debilitating groin disabilities, the 20 percent disability ratings assigned herein indicate a significant impact on his functional ability. Such disability evaluations assigned by VA recognize his pain, indicating very generally a 40 percent reduction in his ability to function due to his bilateral groin disabilities. The critical question in this case, however, is whether the problems he has cited meet even higher levels under the rating criteria. For the reasons cited above, the Board finds they do not, for any part of the initial rating period on appeal. As discussed above, without taking into consideration the problems associated with this disability, the evaluations assigned herein could not be justified, let alone higher evaluations. For these reasons, the Board finds that 20 percent disability ratings, but no higher, are warranted for the right and left groin disabilities for the entire initial rating period on appeal. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. TDIU Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. 38 U.S.C. § 1155. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. 38 C.F.R. § 3.340(a)(1). Total ratings are authorized for any disability or combination of disabilities for which the Rating Schedule prescribes a 100 percent evaluation. 38 C.F.R. § 3.340(a)(2). TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). The central inquiry is "whether the veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to his or her level of education, special training, and previous work experience, but advancing age and the impairment caused by nonservice-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Marginal employment, defined as an amount of earned annual income that does not exceed the poverty threshold determined by the United States Department of Commerce, Bureau of the Census, shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). Substantially gainful employment is work that is more than marginal, which permits the individual to earn a "living wage." See Moore v. Derwinski, 1 Vet. App. 356 (1991). In reaching a determination of TDIU, it is necessary that the record reflect some factor which takes his case outside the norm with respect to a similar level of disability under the rating schedule. 38 C.F.R. §§ 4.1, 4.15; Van Hoose, 4 Vet. App. 361. The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether or not the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Beaty v. Brown, 6 Vet. App. 532, 538 (1994). In this case, the Veteran contends that he is unable to secure employment due to his service-connected disabilities. As noted above, at the June 2011 muscle examination, he reported that he retired from his job as a truck driver in June 2010 due to his bilateral groin disabilities. It also appears from a September 2017 VA Form 21-8940 that he worked from June to November 2016 as a truck driver. VA requested records from the Social Security Administration (SSA), but in October 2017, the SSA responded that no records were found. The Veteran's service-connected disabilities are as follows: PTSD, evaluated as 70 percent disabling from June 16, 2017; right adductor magnus, longus, and brevis muscle strain and tendonitis at the insertions upon the posterior and inferior pubic rami, evaluated as 20 percent disabling from July 26, 2010; and left adductor magnus, longus, and brevis muscle strain and tendonitis at the insertions upon the posterior and inferior pubic rami, evaluated as 20 percent disabling from July 26, 2010. From June 16, 2017, the combined schedular rating criteria for consideration of TDIU under 38 C.F.R. § 4.16(a) are met because the Veteran has a single service-connected disability rated at least 60 percent. After a review of all the evidence, the Board concludes that the evidence is at least in equipoise as to whether the Veteran is unable to secure or follow substantially gainful employment due to his service-connected disabilities from June 16, 2017. The evidence in favor of the claim for TDIU includes the Veteran's statements that he is unemployable due to his service-connected disabilities. In addition, as discussed above, his bilateral groin disabilities produce significant occupational impairment. His PTSD, which is rated as 70 percent disabling, also results in significant occupational impairment. An October 2017 psychiatric examiner opined that his psychiatric disability would produce occupational and social impairment with deficiencies in most areas. The Veteran's wife reported that he is severely depressed and spends most of his time in bed. The examiner noted that his symptoms include depressed mood, anxiety, chronic sleep impairment, memory impairment, flattened affect, difficult in understanding complex commands, gross impairment in thought processes or communication, disturbances of mood and motivation, disorientation to time or place, suicidal ideation, panic attacks more than once per week, and difficulty establishing and maintaining effective work and social relationships. It is clear that the Veteran has significant occupational impairment due to his service-connected disabilities. Therefore, the Board finds that the evidence at least in equipoise as to whether the Veteran is unable to secure gainful employment due to his service-connected PTSD from June 16, 2017, when he met the schedular criteria under 38 C.F.R. § 4.16(a) for consideration of a TDIU. Resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for a TDIU are met from June 16, 2017. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Prior to June 16, 2017, however, the combined schedular rating criteria for consideration of TDIU under 38 C.F.R. § 4.16(a) are not met because the Veteran did not have a single service-connected disability rated at at least 60 percent or a combined schedular rating of at least 70 percent. However, under 38 C.F.R. § 4.16(b), a TDIU evaluation on an extraschedular basis can still be awarded if it is established by the evidence of record that the service-connected disabilities have rendered a veteran unable to secure and follow substantially gainful employment. After a review of all the evidence, the Board concludes that the weight of the evidence demonstrates that referral to the Director of Compensation Service for consideration of an extra-schedular TDIU is not warranted for any part of the rating period prior to June 16, 2017. In this regard, the preponderance of the evidence is not indicative of a finding that the Veteran was unable to secure or follow substantially gainful employment due to his service-connected disabilities. The Board acknowledges that the Veteran has not had consistent full-time employment since 2010, and, as discussed above, that he experienced significant occupational impairment due to his bilateral groin disabilities. However, after acknowledging and discussing the functional limitations caused by his service-connected bilateral groin disabilities in great detail, the June 2011 VA muscle examiner opined sedentary employment was not precluded by his groin disabilities, his only service-connected disabilities prior to June 16, 2017. In sum, the percentage criteria set forth at 38 C.F.R. § 4.16(a) were not met prior to June 16, 2017, and the evidence does not demonstrate that referral under 38 C.F.R. § 4.16(b) to the Director of Compensation Service for consideration of an extra-schedular TDIU due to his service-connected disabilities is warranted for the period prior to June 16, 2017. The Board acknowledges the statements of the Veteran and his examining physicians that, prior to June 16, 2017, he had significant functional impairment due to his service-connected groin disabilities, and this is reflected in the disability ratings assigned herein. The Board does not doubt that his service-connected groin disabilities cause significant occupational impairment. However, while the evidence certainly demonstrates that the Veteran experienced significant occupational impairment due to his service-connected groin disabilities prior to June 16, 2017, the weight of the evidence does not show that that the severity of symptoms warrant extraschedular consideration by Director of the Compensation Service. Rather, as discussed above, the 2011 VA examiner's opinion provides highly probative evidence against the claim for a TDIU for the period prior to June 16, 2017. As such, the preponderance of the evidence is against the Veteran's claim for a TDIU prior to June 16, 2017. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). With regard to the TDIU claim, VA's duty to notify was satisfied by way of an October 2017 letter. Because the initial rating appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for the bilateral groin disabilities, no additional notice is required with regard to those claims. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Court have held that, once service connection is granted and the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App.112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence, including affording a VA examination. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, VA examination reports, and the Veteran's statements, including his testimony at the June 2017 Board hearing. The Court held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the June 2017 Board hearing, the undersigned Veterans Law Judge asked questions pertaining to the criteria necessary for establishing his claims, including regarding specific evidence that may help substantiate his claims. Moreover, neither the Veteran, nor his representative, has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2), and that any error in notice provided during the hearing constitutes harmless error. The Veteran has been afforded an adequate examination on the issue of rating the bilateral groin disabilities. As discussed above, VA provided the Veteran with examinations in December 2010 and June 2011. The Veteran's history was taken, and complete examinations with clinical measures were conducted, to include review of a x-ray studies when applicable. Conclusions reached and diagnoses given were consistent with the examination reports, including notation of whether there were additional losses of ranges of motion due to factors such as painful motion, weakness, impaired endurance, incoordination, or instability. Therefore, the Veteran has been afforded an adequate examination on the issue decided herein. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board acknowledges the Veteran's testimony at the June 2017 Board hearing that his December 2010 VA Genitourinary examination was inadequate as the examiner did not explain what he was going to do during the examination and the Veteran was afraid the examiner was going to hurt him. However, the Board notes that, subsequently, another VA Genitourinary examination was conducted in June 2011 by a different examiner, and that examiner found no current genitourinary conditions, stating that the Veteran's service-connected muscle and tendon disability is often misinterpreted as having genitourinary causes. Therefore, a new VA Genitourinary examination is not necessary, and to the extent that the December 2010 VA examination was not adequate, he was already afforded a new examination in June 2011. Moreover, the Veteran requested a new VA examination at the Board hearing as the most recent June 2011 VA examination is more than six years old. However, the Veteran did not state that his bilateral groin disabilities had worsened since the 2011 examination, and, moreover, the VA treatment records and statements of the Veteran and his wife since that time provide adequate information upon which to determine the appropriate disability ratings in this case. The age of the VA examination, by itself, is not a sufficient basis upon which to remand this case for a new examination. Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD T. Sherrard, Counsel Copy mailed to: The American Legion Department of Veterans Affairs