Citation Nr: 1804111 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 16-28 394 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for right great toe arthritis. 2. Entitlement to service connection for migraine headaches. 3. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with depressive disorder, to include entitlement to a total rating based on individual unemployability by reason of service-connected disability (TDIU) REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and his partner ATTORNEY FOR THE BOARD C. Jones, Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The Veteran had active service from May 2001 to May 2005; from January 2006 to January 2008; from January 2009 to October 2009; and from October 2011 to November 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. The Veteran testified before the undersigned at a Board videoconference hearing in October 2017. A transcript of the hearing has been associated with the claims file. The Board observes that the issue of entitlement to a TDIU was denied in an April 2017 rating decision. The Veteran did not appeal. Notwithstanding, the Board notes that entitlement to a TDIU is an element of a claim for an increased disability rating, when raised by the Veteran or the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to a TDIU due to PTSD was explicitly raised by the Veteran in his December 2016 application for TDIU and the issue was discussed during the October 2017 Board hearing. Therefore, it has been included as an issue above, as part and parcel of the Veteran's claim for an increased rating for PTSD. The issues of entitlement to service connection for right great toe arthritis is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In testimony provided during the October 2017 Board videoconference hearing, prior to the promulgation of a decision in the appeal, the appellant indicated that he wished to withdraw the issue of entitlement to service connection migraine headaches. 2. Resolving doubt in favor of the Veteran, the Veteran's PTSD has been manifested by symptoms which cause occupational and social impairment with deficiencies in most areas; the symptoms have not caused total occupational and social impairment. 3. The Veteran's service-connected PTSD renders him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal have been met with respect to the issue of entitlement to service connection for migraine headaches. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria for a rating 70 percent rating, but no higher, for posttraumatic stress disorder (PTSD) with depressive disorder have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code 9411 (2017). 2. The criteria for a total rating based on individual unemployability due to service-connected disability (TDIU) have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Withdrawal of the Issue of Entitlement to Service Connection for Migraine Headaches Under applicable criteria, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (2012). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2017). An appeal may be withdrawn on the record at a hearing or in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202, 20.204. Withdrawal may be made by an appellant or by his or her authorized representative. 38 C.F.R. § 20.204. Withdrawal of a claim is only effective where the withdrawal is explicit, unambiguous, and done with a full understanding of the consequences of such action on the part of the claimant. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011) ("Although Mr. DeLisio 'thought' that the Board member had identified the issues to be discussed, the transcript reflects neither an explicit discussion of withdrawal nor any indication that Mr. DeLisio understood that he might be withdrawing claims for benefits for any disabilities not discussed."). In the present case, in testimony provided during the October 2017 Board videoconference hearing, the Veteran indicated that he wanted to withdraw his appeal with respect to the issue of entitlement to service connection for migraine headaches. Based on the Veteran's hearing testimony, the Board finds that the criteria for a withdrawal of the appeal have been met. Thus, the Board finds that there remain no allegations of errors of fact or law for appellate consideration for this claim. Accordingly, the Board does not have jurisdiction to review claim, and it is dismissed. Entitlement to an Increased Rating for PTSD Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a "staged rating" (i.e., assignment of different rating for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Veteran's PTSD has been rated under the criteria contained in the General Rating Formula for Mental Disorders. Under those criteria, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). A 70 percent rating is assigned when there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place, memory loss for names of close relatives, own occupation, or own name. Id. In Mauerhan v. Principi, 16 Vet. App. 436 (2002), the U.S. Court of Appeals for Veterans Claims (Court) held that use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the evidence considered in determining the level of impairment under section 4.130 is not restricted to the symptoms provided in the diagnostic code. Rather, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. More recently, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed.Cir 2013). The Federal Circuit explained that in the context of a 70 percent rating, section 4.130 "requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. at 118. The Federal Circuit indicated that "[a]lthough the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in most areas.'" Id. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, a Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) (DSM-IV)). The Board notes that effective August 4, 2014, VA implemented rules replacing references to the DSM-IV with the DSM-5. The DSM-5 applies to claims certified to the Board on and after August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). The Veteran's appeal was certified to the Board in June 2016. Consequently, the DSM-5 is for application to his appeal. The DSM-5 does not contain information regarding GAF scores. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (2014); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Factual Background VA treatment records from August 2014 to December 2014 note treatment for PTSD symptoms. Such symptoms include of intrusive memories, anger, and anxiety. The Veteran underwent a VA examination in December 2014 at which time he was assessed with moderately severe to severe PTSD; depression secondary to PTSD, impacted by health concerns; and alcohol abuse, early partial remission. The examiner opined that it was not possible to differentiate what symptoms are attributable to each diagnosed condition. Symptoms associated with the Veteran's psychiatric conditions included depressed mood, anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work like setting, and an inability to establish and maintain effective relationships. On mental status examination, it was noted that the Veteran was dressed in casual attire and was clean and well groomed. He was fully oriented in all spheres. His responses to questions of content were thoughtful, complete, and he demonstrated an adequate fund of knowledge. The examiner noted that the appellant presented as an honest historian. The Veteran's speech pattern was of a regular rhythm and volume of speech was full and normal. The Veteran's expressed thoughts were well organized to topic. There was no indication of psychotic processes, delusional disorder or loosened associations of organicity. The Veteran did have moderate somatic concerns, secondary to chronic low back pain. His affect was moderately restricted and his dominant mood was moderately depressed. The Veteran denied any suicidal or homicidal ideation, plans, or intent. He did not have concerns regarding future events, primarily future employment as well as anticipated birth of his daughter. The Veteran's alcohol and drug surveys were negative though the Veteran did report a prior history of alcohol abuse. The examiner noted that the Veteran continued to reside in Puyallup, Washington, where he had lived since 2012. The appellant reported that he has 2 sons and was anticipating the birth of a daughter within the next few days. He was not married. The Veteran also reported that had had been a full-time student at a technical college since October 2013 and anticipated graduation in February 2015 and planned to transfer to a 4-year school to obtain a bachelor's degree in psychology. The Veteran reported that his grade point average was a 3.0. Notwithstanding, he did report having a history of difficulty with a professor, however, it had been resolved. He reported an overall ability to attend to his own daily needs including meals, hygiene, medications, and to pay bills in a timely manner. The examiner noted that the Veteran presented with continued symptoms of PTSD moderately severe to severe. He noted that the Veteran reported daily intrusive thoughts and recollection regarding past traumas that give rise to symptoms of anxiety, irritability, and outburst of verbal anger followed by periods of depression and anhedonia. He also reported actively avoiding certain conversations and places which could recall past traumas. The Veteran described some loss of interest in previously enjoyed activities though reported enjoying playing with his sons. It was documented that he presented with restricted range of affective response. Evidence of hyperarousal was indicated by moderate vigilance in unfamiliar social settings such as crowds, which the Veteran avoids. The Veteran also reported sleep impairments, waking secondary to night sweats and nightmares. The examiner opined that the overall impact of the of the Veteran's present psychological stress does reduce his reliability and productivity in social, occupational, and family capabilities secondary and interactive to symptoms of PTSD and depression. Medical records subsequent to the December 2014 VA examination demonstrate continued psychiatric treatment. Notably, in March 2015, the Veteran reported the onset of nausea and vomiting. The Veteran presented for emergency room treatment for such symptoms in March 2015 and April 2015. In an April 2015 statement it was noted that the Veteran had been unable to attend drill due to severe intermittent nausea and vomiting. The records also note suicidal ideation. Mental health records dated from October 2016 to December 2016 note that the Veteran was in an intensive outpatient program. In the October 2016 referral questionnaire, it was noted that the Veteran has 2 sons and 1 daughter, all by different women. He reported that he had not seen his daughter since she was 4 months old as his ex-partner filed a restraining order against him. He currently lived with his girlfriend of two years. Occupationally, it was noted that the Veteran was honorably discharged from the Army National Guard in 2015. He was currently unemployed with his last period of employment for the National Guard in September 2013. Endorsed symptoms included intrusive distressing memories, avoidance, irritability, angry behavior (including punching walls), depressed mood, low energy, and decreased appetite. In records dated in April 2017, the Veteran reported suicidal ideations, but noted that it was "normal for him." However, he denied any plan or intent or history of self-harm or suicide attempts. He indicated that his children were a strong protective factor against suicide. In April 2017, he presented to the psychiatry emergency department accompanied by his girlfriend with suicidal ideation in setting of alcohol intoxication. His girlfriend reported that he had been suicidal for 3 years. In testimony provided during the October 2017 Board hearing, the Veteran reported that he felt suicidal or thought about suicide or death on a daily basis. The Veteran's girlfriend reported that he had a recent suicide attempt in April 2017 and that she had to take him to the emergency room. Obsessional rituals which interfere with routine activities were also reported. The appellant indicated that he has a daily schedule and that he if he cannot fulfill the scheduled tasks he gets anxious. His girlfriend stated that if anything causes the Veteran to deviate from the schedule, he starts sweating profusely and has near continuous panic attacks or depression. Impaired impulse control was also noted. The Veteran also stated that he does not have any communication with his children and does not talk to his friends. With regard to hygiene, he stated that he struggled with changing clothes, showering, and brushing his teeth. His girlfriend stated that the Veteran's PTSD is very debilitating. She had lost approximately 50 days from work taking care of him. The Veteran reported that he last attended school in July 2017 at which time he was asked to medically withdraw from school. His girlfriend reported that the Veteran was admitted to inpatient for his PTSD in August 2017 and stayed for 45 days. Analysis Applying criteria set forth above to the facts in this case; the Board finds that, resolving doubt in favor of the Veteran, the evidence warrants a schedular rating of 70 percent for the Veteran's service-connected PTSD. The above reflects that the Veteran has experienced obsessed rituals, suicidal ideation, near continuous panic attacks or depression, and neglect of personal appearance and hygiene. Such symptoms are listed in the criteria for a 70 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). The Board acknowledges that the December 2014 VA examiner opined that the Veteran's PTSD symptoms caused occupational and social impairment with reduced reliability and productivity. However, the ultimate determination of the degree of occupational impairment is a legal rather than a medical determination. 38 C.F.R. § 4.2 ("It is the responsibility of the rating specialist to interpret reports of examination ... so that the current rating may accurately reflect the elements of disability present."); VA Adjudication Procedures Manual, M21-1, Part III, Subpart. iv, Chapter 3, Section A.7.i (updated Oct. 28, 2015) ("Do not request a medical authority to make conclusions of law, which is a responsibility inherent to the rating activity"). Moreover, in Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017), the Court held that the language of the general rating formula "indicates that the presence of suicidal ideation alone . . . may cause occupational and social impairment with deficiencies in most areas." The Court also held that "insofar as the Board required evidence of more than thought or thoughts to establish the symptom of suicidal ideation, it erred." Id. Based on the Court's holding and reasoning in Bankhead and the other evidence above showing other symptoms listed in the criteria for a 70 percent rating and significant occupational and social impairment, the Board finds that the Veteran's symptoms more nearly approximated the criteria for a 70 percent rating. In sum, the Board finds that throughout the rating period on appeal, a 70 percent rating is warranted for the Veteran's PTSD. However, the Veteran's PTSD symptoms have not more nearly approximated total occupational and social impairment at any point during the appeal period. 38 C.F.R. § 4.7 (2017). Symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time and place; memory loss for names of close relatives, own occupation or name, have not been shown. The evidence indicates that the Veteran experienced suicidal ideation, and has reported that he was asked to withdraw from school. As set forth below, the Board has determined that the Veteran's PTSD has produced total occupational impairment. Critically, however, the evidence does not show total occupational and social impairment due to PTSD. He is shown to maintain a relationship with his girlfriend and children. Thus, neither the symptoms nor overall level of impairment meet the criteria for a 100 percent rating under the Rating Schedule, and a rating in excess of the 70 percent assigned herein is therefore not warranted for the Veteran's PTSD. Entitlement to a TDIU VA disability ratings are based, as far as practicable, on the average impairment of earning capacity attributable to disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.10 (2017). Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Id. Where the schedular rating is less than total, a total disability rating may nonetheless 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 disability; provided that, in pertinent part, if there is only one such disability, the disability shall be rated at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability rated 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment. See 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). In reaching such a determination, 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). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion. Individual unemployability, however, must be determined without regard to any nonservice-connected disabilities or advancing age. 38 C.F.R. §§ 3.341(a), 4.16, 4.19 (2017); Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or maintain employment, but the ultimate 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, 4 Vet. App. at 363. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Factual Background and Analysis The Veteran asserts that a TDIU is warranted. Specifically, he contends that he is unemployable due to his PTSD. The Veteran is service connected for PTSD, rated as 70 percent disabling. This disability alone meets the percentage requirements set forth in section 4.16(a) for consideration of TDIU. His other service-connected disabilities include right knee tendonitis, rated as 10 percent disabling; right elbow epicondylitis, rated as 10 percent disabling; lumbar spine strain, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling; and chronic right ankle pain, rated as 10 percent disabling. His combined disability rating is 80 percent. See 38 C.F.R. § 4.25 (2016). Because the appellant meets the percentage requirements set forth in section 4.16(a) for consideration of a TDIU, the remaining question is whether the Veteran's service-connected disabilities precluded gainful employment for which his education and occupational experience would otherwise qualify him. As detailed herein, the Veteran underwent a VA examination in December 2014 for his service-connected PTSD. At that time, it was noted that the Veteran was enrolled in school, however he was unemployed. The examiner indicated that the Veteran's PTSD caused reduced reliability and productivity in social, occupational, and family capabilities. In December 2016, the appellant submitted a VA Form 21-8940 (Veterans Application of Increased Compensation Based on Unemployability) on which he claimed that he was unemployable due to his PTSD. He reported that he was last employed full-time as a staff sergeant in the U.S. Army on October 31, 2013. He claimed that he became too disabled to work on November 5, 2013. He stated that although he had been employed full-time from May 2001 to September 2015 in the U.S. Army, he had lost 23 months lost due to illness. (The Board notes that this period of service is not active duty; rather, it reflects his membership in the National Guard. The Veteran's last verified period of active duty in the record currently available to the Board ended in September 2012 when he returned from Afghanistan). The Veteran indicated that he had not tried to obtain employment since becoming too disabled to work on November 5, 2013. With regard to education, the appellant documented that he completed high school and completed three years of technical college. He reported that he began college in January 2015 but did not complete his educational courses. He reported that he had to medically withdraw from the program due to his illness, which included frequent episodes of nausea and vomiting related to PTSD. In testimony provided during the October 2017 Board videoconference hearing, the Veteran reported that he was working on a degree in welding technology. The appellant's girlfriend reported that during his last month of school, there were 28 calendar days of school. However, the appellant only attended class 3 days, and those 3 days he was only present for 2 hours. He was sent home because of panic, anxiety, and vomiting. It was noted that the Veteran last attended school in June 2017. He was asked to medically withdraw from school. She also stated that the Veteran last worked in September 2013. Applying the criteria set forth above to the facts in this case, and resolving all doubt in favor of the Veteran, the Board finds that the Veteran's service-connected PTSD has precluded him from substantial gainful employment; therefore, assignment of a TDIU is warranted. In so finding, the Board acknowledges that the December 2014 VA examiner opined that the Veteran's PTSD caused only reduced reliability and productivity in social, occupational, and family capabilities. As detailed above, however, the Veteran has reported that he has been unemployed since October 31, 2013, and unable to work since November 5, 2013, Notably, the Veteran's occupational history consists solely as an infantryman in the U.S. Army. While the Veteran enrolled in college to obtain a welding technology degree, he was asked to medically withdraw from school due to his PTSD symptoms. In light of the foregoing evidence, and resolving all doubt in the Veteran's favor, the Board finds that entitlement to a TDIU is warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.16(b). ORDER Entitlement to service connection for migraine headaches is dismissed. Entitlement to an initial rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) with depressive disorder is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a total disability rating based on unemployability due to service-connected disability (TDIU) is granted, subject to controlling regulations governing the payment of monetary awards. REMAND The Veteran asserts that service connection is warranted for right great toe arthritis. Specifically, he contends that he broke his toe while in basic training in 2001 at which time he received treatment at the Martin Army Hospital between July 2001 and August 2001. See also Buddy/Lay Statement, received 12/05/2017. The appellant asserts that he has suffered from right great toe pain and arthritis since the injury. At the outset, the Board observes that the service treatment records for the Veteran period of service from May 2001 to May 2005, to include records from Martin Army Hospital have not been associated with the claims file. On remand, outstanding service treatment records must be obtained. The Veteran underwent a VA foot conditions examination in January 2015. The examiner diagnosed hallux rigidus and degenerative arthritis, however an etiological opinion was not provided. Thus, the January 2015 VA examination is insufficient to determine the Veteran's service connection claim. As such, an additional VA examination must be provided on remand. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Undertake the necessary efforts to obtain any outstanding service treatment records, to include records from May 2001 to May 2005 and records from Martin Army Hospital regarding treatment for a right great toe injury. Efforts to obtain these records must continue until they are obtained or it is reasonably certain that they do not exist or that further efforts would be futile. All efforts to obtain outstanding service treatment records should be documented in the claims folder. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his right great toe disability. Access to records in the Veteran's electronic claims file should be made available to the examiner for review in connection with his or her opinion. Following examination for the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's right great toe disability was incurred in service or is otherwise causally related to his active service or any incident therein? A clear explanation for the VA medical opinion is required, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner cannot respond without resorting to speculation, it should be explained why a response would be speculative. In rendering an opinion, the examiner must discuss the Veteran's report regarding an in-service injury. 3. After undertaking any development deemed necessary, readjudicate the remaining issue on appeal, considering all the evidence of record. If the benefits sought on appeal remain denied, provide the Veteran with a Supplemental Statement of the Case and the opportunity to respond. The case should then be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ K. Conner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs