Citation Nr: 1804263 Decision Date: 01/22/18 Archive Date: 01/31/18 DOCKET NO. 09-12 164 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for bilateral hand disability, claimed as generalized joint pain and/or osteoarthritis. 2. Entitlement to service connection for bilateral elbow disability, claimed as generalized joint pain and/or osteoarthritis. 3. Entitlement to service connection for bilateral wrist disability, claimed as generalized joint pain and/or osteoarthritis. 4. Entitlement to service connection for bilateral foot disability, claimed as generalized joint pain and/or osteoarthritis. 5. Entitlement to a disability rating in excess of 10 percent for left facial nerve impairment, as a residual of Bell's palsy. 6. Entitlement to a compensable rating for dysphagia, with mild difficulty of swallowing, as a residual of Bell's palsy. 7. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 8. Entitlement to special monthly compensation (SMC) at the housebound rate. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C.S. De Leo, Associate Counsel WITNESSES Veteran and his Wife INTRODUCTION The Veteran served on active duty from May 1985 to July 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA) in Indianapolis, Indiana. In March 2017, the Board remanded the claim to the Agency of Original Jurisdiction (AOJ) for further development to include scheduling a Board hearing. For the reasons discussed below, the Board finds that there has been substantial compliance with the development sought as part of the March 2017 remand. Stegall v. West, 11 Vet. App. 268 (1998). In June 2017 the Veteran testified at a Board video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. FINDINGS OF FACT 1. The Veteran does not have a bilateral hand disability, claimed as generalized joint pain and/or osteoarthritis due to disease or injury in active military service. 2. The Veteran does not have a bilateral elbow disability, claimed as generalized joint pain and/or osteoarthritis due to disease or injury in active military service. 3. The Veteran does not have a bilateral wrist disability, claimed as generalized joint pain and/or osteoarthritis due to disease or injury in active military service. 4. The Veteran does not have a bilateral foot disability, claimed as generalized joint pain and/or osteoarthritis due to disease or injury in active military service. 5. The Veteran's left facial nerve impairment, as a residual of Bell's palsy is manifested by incomplete moderate paralysis of the cranial nerve. 6. The Veteran's dysphagia, with mild difficulty of swallowing, is not manifested by incomplete paralysis of the tenth (vagus) cranial nerve. 7. The Veteran's service-connected headache disability precludes him from securing or following a substantially gainful occupation. 8. Based on the Board's award of TDIU as a result of the Veteran's service-connected headache disability, the Veteran had a single service-connected disability rated at 100 percent plus additional service-connected disabilities having a combined rating of 60 percent or more. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral hand disability claimed as generalized joint pain and/or osteoarthritis have not all been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.310 (2017). 2. The criteria for service connection for a bilateral elbow disability claimed as generalized joint pain and/or osteoarthritis have not all been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.310 (2017). 3. The criteria for service connection for a bilateral wrist disability claimed as generalized joint pain and/or osteoarthritis have not all been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.310 (2017). 4. The criteria for service connection for a bilateral foot disability claimed as generalized joint pain and/or osteoarthritis have not all been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.310 (2017). 5. The criteria for an increased rating greater than 10 percent for left side facial cranial nerve impairment have not all been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.655, 4.1, 4.2, 4.7, 4.124a, DC 8307 (2017). 6. The criteria for compensable dysphagia, with mild difficulty of swallowing, as a residual of Bell's palsy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.6, 4.7, 4.124a, DC 8210 (2017). 7. The criteria for TDIU have all been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16 (2017). 8. The criteria for SMC at the housebound rate have all been met. 38 U.S.C. §§ 1114 (s), 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.350(i) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See eg. 38 U.S.C. §§ 5103, 5103A (2012) and 38 C.F.R. § 3.159 (2017). In the instant case, VA provided adequate notice in letters sent to the Veteran in July 2007. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service and VA treatment records are associated with the claims file as are records associated with his claim for disability benefits from the Social Security Administration (SSA). VA provided relevant examinations as discussed in further on in the decision. There is no indication of additional existing evidence that is necessary for a fair adjudication of these claims that are the subject of this appeal. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. II. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2017). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, including arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112, (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2017). Background Bilateral Foot, Hand, Elbow, Wrist, and Foot Conditions (claimed as generalized joint pain and osteoarthritis) At the onset, the Board notes that service connection has already been established for the Veteran's bilateral thumb strain, radiculopathy of the bilateral upper extremities with residuals of carpal tunnel, status post release surgery, and residuals of bilateral carpal tunnel syndrome, status post release surgery. In this regard, the Veteran has been provided multiple VA examinations to determine the etiology of any joint condition manifested by pain or osteoarthritis. By way of background, a February 2008 rating decision granted service connection for several disabilities and denied service connection for generalized joint pain, also claimed as osteoarthritis of the bilateral shoulders, elbows, wrists, hands, thumbs, hips, ankles, feet, and left knee. Specifically, the Veteran seeks service connection for bilateral foot disability. During the Board hearing, the Veteran testified that he was diagnosed with plantar fasciitis and Morton's neuroma in August 2011. He reported pain under the arch and that he started wearing orthotics in 2006 to ensure his feet were properly positioned. He reported obtaining orthotics from the VAMC in Indianapolis as well and also that a clinician advised him that these are all similar issues to those he experienced during military service. Notably, an August 2008 private treatment record from Foot & Ankle Institute shows the Veteran presented with complaints of bilateral arch pain and was diagnosed with bilateral plantar fasciitis and Morton's neuroma. The resulting examination report notes that the clinician discussed etiology with the Veteran however there are no specific details and no associated etiology opinion. Pertinent evidence of record includes service treatment records and post-service VA treatment records. The Veteran's service treatment records do show complaints and treatment for joint pain in multiple joints during active service to include multiple medical examinations. X-ray findings however did not identify osteoarthritis. Specifically, medical examination reports for periodic or annual flying dated in February 1984, July 1985, September 1986, August 1987, September 1989, August 1991, August 1994, September 1997, October 1998, and September 2001 show the Veteran received a normal clinical evaluation with regard to any related system or anatomy. Medical conditions noted were related to the skin, bilateral valsalva, upper respiratory infection (URI), and asymptomatic small left varicocoele. A report of Medical History dated in July 1985 show the Veteran denied swollen and painful joints, painful or trick shoulder or elbow, and foot trouble. Additionally, medical examinations for flying personnel dated in September 1992 and August 1993 indicate the Veteran denied any medical history related to problems with joint pain or injury. There are also several medical examinations related to recommendation for flying personnel or special operational duty dated throughout active service specifically related to the Veteran's vision, however consistent with the Veteran's examinations indicating no joint pain or injury. A January 2001 Report of Medical Assessment indicates the Veteran checked "no" stating that he had never suffered from any injury or illness while on active duty for which he did not seek medical care. In a March 2002 Annual Medical Certificate, the Veteran indicated having no current medical problems. An August 2003 and September 2006 Health History Questions/Interval History notes the Veteran answered "no" to having any recent bothersome medical problems or symptoms. Service treatment records show the Veteran was treated with ice for a contusion of the left hand in August 1984. No further complaints of the left hand were shown. A November 1986 service treatment record notes the Veteran presented with muscle aches and congestion. The assessment was URI. A June 1990 service treatment records issuance of foot inserts due to a high arch in the bilateral feet but concluded there was no pes cavus. A medical problem list documents osteoarthritis, joint instability ankle/foot, and acquired deformity of foot, noted as cavus. In September 2006 the Veteran presented with complaints of bilateral wrist pain on and off for 10 years, numbness, and tingling in the fingers. He was diagnosed with carpal tunnel syndrome confirmed by x-rays. He underwent carpal tunnel release in October 2006. In October 2006 there was also a provisional diagnosis of cavovarus feet. Subsequent service treatment records consistently note the Veteran reported bilateral foot pain since high school and having inserts made at that time. He requested inserts for support to include the ankle. He also reported instability of the feet. Examination revealed bilateral high arch and the examiner concluded the arch was without C shaped indicating pes cavus. The examiner further noted that the device for the Veteran's feet would be made due to his symptoms. A May 2007 separation examination report notes the examiner gave a normal clinical evaluation with regard to any relevant system or anatomy to include finding the Veteran had a normal arch. The associated medical history report shows the Veteran answered "yes" to having had or currently having painful shoulders, elbows and wrists, arthritis, rheumatism, or bursitis, foot trouble, and impaired use of arms, legs, hands, or feet. The Veteran reported current pain associated with headaches and his back. He also reported bilateral carpal tunnel syndrome release, a September 2000 shoulder injury, as well as the intent to seek VA disability benefits for conditions related to headaches, shoulders, wrists, knees, back, ankles, hands, hips, and hearing. He also explained having had or currently having painful knees, ankles, wrists, elbows, shoulders, hands, fingers and thumbs, osteoarthritis and carpal tunnel syndrome. The healthcare provider specifically documented pain associated with headaches, low back, neck, knees, and shoulders, noting osteoarthritis and pain syndrome. The provider also documented carpal tunnel syndrome status post release in 2006, with recurrent symptoms after some development. With respect to his bilateral elbows claim, during the Board hearing, acknowledging that x-rays identified no fracture or dislocation, the Veteran explained that pain started during active service while he was in the Cadets at the United States Air Force Academy in 1984. He reported difficulty doing pushups, also explaining that aircrew duties included lifting, pushing, and carrying things; as well as climbing, jumping, and pulling yourself up in aircraft because there is no ladder. He reported participation in physical training during the Academy, and thereafter participation in jump school, navigation school and Squadron Officer's school, where he participated in daily physical training, which exacerbated his elbow problems. With respect to the bilateral hands claim , during the Board hearing the Veteran testified that he had not received any additional diagnoses of the hands other than those for which he is currently service connected. He reported that instead he was informed that x-rays identified normal hands. Concerning the additional disability for the bilateral hands, the Veteran reported that during active service his duties included grabbing and lifting things to include carrying bags and at this time he experienced difficulty grasping and lifting items when utilizing the entire hand, thumbs, and fingers. Additionally, he explained following carpal tunnel release surgery, his grip strength decreased despite occupational therapy with symptoms to include cracking and popping. He also described multiple symptoms related to the wrist, to include pain, the inability to grasp and lift items, as well as decreased strength during normal activities using the wrists such as pressing, turning, and operating equipment while training pilots. He stated that other than bilateral carpal tunnel syndrome he had not been diagnosed with any other condition related to the wrist, which increased in severity following surgery to treat bilateral carpal tunnel in 2006 during service. During the appellate period, the Veteran was afforded several VA examinations in September 2007, December 2009, and January 2013 as well as VA medical opinions in May 2014 and May 2016 to determine the etiology of joint pain. The resulting examination reports show the Veteran was afforded joint examinations to determine the etiology of any identifiable condition related to symptoms of impairment to include joint pain of the bilateral hands, elbows, wrists, and feet. In September 2007 the Veteran underwent multiple VA examinations. A September 10, 2007 VA hand, thumb, and fingers examination, shows the Veteran reported decreased mobility due to pain. The resulting examination report indicates the examiner reviewed the claims file. The examiner opined that x-rays of the bilateral hands, wrists, and ankles were unremarkable. The diagnosis was generalized joint pain with no significant injury. There was a normal exam of elbows with normal muscle strength of the bilateral elbows and also normal strength of the wrists. On examination, the Veteran had generalized pain in both elbows with rare locking. He reported pain and weakness associated with the wrists and wearing a brace for support. Sensory examination of the lower extremities was normal. Additionally, reflex exam was 1 plus with the exception of absent on finger jerk. A September 10, 2007 VA feet examination did not identify there was plantar fasciitis or Morton's neuroma. The Veteran endorsed symptoms of constant, aching pain, occasional sharp pain, weakness, and instability, and limited mobility due to pain. He reported generalized aching pain to the arches and occasional shooting pain to the heels. A September 27, 2007 VA general medical examination notes the Veteran reported osteoarthritis of all major joints described as bilateral elbow pain, sensitivity of the hands, and bilateral wrist pain, with a gradual onset during service. He reported treatment to include physical therapy, occupational therapy, and NSAIDS. He also reported a left hand injury in 2001 during service. Examination revealed pain, stiffness, and limited motion of the bilateral elbows and wrists. There was also decreased strength and dexterity of the hands. Otherwise examination of the joints was normal to include normal x-rays of the bilateral elbows, wrists, and hands. The examiner diagnosed bilateral elbow pain, heat/cold tolerance of the bilateral hands, left hand injury, resolved, arthralgia of all major joints, and residuals of bilateral carpal tunnel releases. In December 2009, the Veteran was afforded VA peripheral nerves examination of the upper extremities. He was diagnosed with bilateral carpal tunnel syndrome, post-surgery manifested by symptoms of wrist pain, numbness, and tingling. A January 2013 VA foot examination notes diagnosis of metatarsalgia in 2006 during service. The resulting examination report indicates the Veteran does not have any other foot conditions to include Morton's neuroma or plantar fasciitis. X-rays identified tiny heel spur on the left foot and there was no arthritis. Right foot x-rays were normal. It was also noted that the Veteran used a cane occasionally to ambulate. Following examination, the examiner opined that it was at least as likely as not (50 percent probability or greater) that the claimed foot disability was incurred in or caused by the claimed in-service injury, event, or illness. The rationale was the Veteran does not have current foot disability of metatarsalgia, which was diagnosed during active service. Noting that the Veteran is aware this condition had resolved, he did have pain in the forefoot, which he described as the same pain he experienced during active service, which is alleviated with orthotics and proper footwear. A January 2013 Hand and Finger Conditions Disability Benefits Questionnaire (DBQ) notes diagnosis of strain of bilateral thumbs in 1995 during service. The resulting examination report notes the Veteran reported onset of pain in both thumbs due to using controllers in B-1 aircraft. He reported he was evaluated at the terminal physical but did not seek treatment at medical. He reported decreased grip due to pain. Examination of the hands identified no tenderness or pain to palpation for joints or soft tissue for either hand. Muscle strength testing revealed normal hand grip, bilaterally. X-rays of the hands were normal and there was no arthritis. Following examination the examiner concluded that there were no other pertinent physical findings, complications, conditions, signs and/or symptoms related to the diagnosis of bilateral thumb strain. Following examination there was no limitation of extension or evidence of painful motion for the index or long finger. There was no functional loss or impairment, or additional limitation in range of motion of any of the fingers or thumbs following repetitive-use testing. The examiner opined that it was less likely as not (50 percent probability or greater) that the claimed in-service injury was incurred in or caused by the claimed in-service injury, event, or illness. The rationale was x-rays did not identify degenerative changes in joints of the hands. A January 2013 Wrist Conditions DBQ indicates diagnosis of bilateral carpal tunnel syndrome, status post release with residuals diagnosed in 2006. The Veteran reported the onset of pain in both hands resulting in surgery to release the median nerve. He reported pain in both wrists with use of the hands such as twisting and turning the wrists at angles. He also reported decreased strength due to pain and weakened grip. He reported medical treatment post-surgery but no treatment within the last 12 months with the exception of using splints occasionally and NSAID to alleviate wrist pain. X-rays identified no arthritis. The examiner concluded that there were no other significant diagnostic test findings related to the wrists and opined that it was at least as likely as not (50 percent probability or greater) that the claimed in-service injury was incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale was despite surgery for carpal tunnel syndrome, and although findings may not be conclusive in all cases, an EMG conducted in 2010 was negative for neuropathy. In May 2014 a medical opinion was obtained to determine whether in service complaints of joint pain of the bilateral thumbs, feet, left hand, and wrists were the early manifestations of any current diagnosed disability. The VA clinician, a nurse practitioner, reviewed the claims file in rendering a medical opinion. With respect to the bilateral feet, the reviewer opined that it was less likely than not (less than 50 percent probability) that subjective complaints of bilateral foot pain was incurred in or caused by the claimed in service injury, event, or illness, and concluded there was no objective findings to support a diagnosis. The reviewer's rationale was the Veteran's service treatment records show an October 2007 diagnosis of acquired pes cavus by podiatry, treated with orthotics. However on his subsequent May 2007 separation medical history report there is no documentation of foot trouble. Additionally, noting foot pain on examination in September 2007 and January 2013, consistent with the findings of these examiners, the May 2014 reviewer concluded there were no objective findings to support a foot disability of the joints to service. With respect to bilateral thumb pain, the reviewer opined that it was at least as likely as not (50 percent or greater probability) that current thumb strain is related to in-service complaints of thumb pain due to working the joystick while he was flying. The clinician's rationale was medical literature provides that repetitive motion disorders (RMDs) are a family of muscular conditions that result from repeated motions performed in the course of normal work or daily activities, which are caused by too many uninterrupted repetitions of an activity or motion, unnatural or awkward motions such as twisting the arm or wrist, overexertion, incorrect posture, or muscle fatigue. The reviewer noted that RMDs occur most commonly in the hands, wrists, elbows, and shoulders and the disorders are characterized by pain, tingling, numbness, visible swelling or redness of the affected area, and the loss of flexibility and strength. The reviewer explained that in some individuals, there may be no visible sign of injury, although they may find it hard to perform easy tasks over time. Therefore it is at least as likely as not that current bilateral thumb strain is related to his military service. With respect to left hand pain, the reviewer opined that it was less likely than not (less than 50 percent probability) that left hand pain was incurred in or caused by the claimed in service injury, event, or illness. In so finding, the reviewer noted the Veteran was treated for a left hand contusion in 1984 with no sequela and he did not report a hand condition on the January 2013 VA examination, but did report having a thumb condition. With respect to bilateral wrists pain, the reviewer opined it was at least as likely as not (50 percent or greater probability) that wrist pain was incurred in or caused by the claimed in service injury, event, or illness. Noting the Veteran's reports of bilateral wrists pain after his carpal tunnel release, and noting that the medical evidence does not note any other wrist condition, the reviewer concluded that bilateral wrists pain is at least as likely as not related to history of carpal tunnel release. In May 2016, a medical opinion was obtained by a VA nurse practitioner, to determine the etiology of right hand pain. The clinician reviewed the claims file and opined that a right hand disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale was there was no evidence of current right hand condition. In so finding, the reviewer noted that the Veteran's VA examination in January 2013 diagnosed bilateral thumb strain in 1995, which resolved as x-rays were normal with limited range of motion. The reviewer concluded that it is less likely as not (50 percent or greater probability) that in service complaints of right hand pain impairment were the early manifestations of any current diagnosed right hand disability. Analysis As discussed above the pertinent evidence, both lay and medical, to include multiple VA examinations and medical opinions dated in September 2007, December 2009, and January 2013, and VA medical opinions dated in May 2014 and May 2016, the clinicians concluded the claimed musculoskeletal disabilities of the left and right hands, wrists, and elbows, and left and right foot, to include osteoarthritis of the joints, are currently without diagnosable symptomatology. Additionally, x-rays of the joints continue to identify normal joints without osteoarthritis. During the appellate term, VA treatment records show the Veteran presented for treatment of the elbow noting the Veteran's reports of an October 2009 injury. He was diagnosed with right elbow pain. He also reported numbness and tingling of the hands in which he associated with bilateral carpal tunnel syndrome. VA treatment records also show the Veteran reported with joint pain of multiple joints. The treatment records are consistent with the findings of the VA examiners. Additionally, a November 2017 statement from Dr. P.A.B., a private clinician of Franciscan Physician Network Sports Medicine Specialist, indicates that he reviewed the Veteran's claims file and noted his reports of chronic pain for the last several years. Dr. B. opined that bilateral hand pain, bilateral wrist pain, and shoulder pain were related to osteoarthritis caused by overuse during the Veteran's military service and his responsibilities working in planes. There is no further discussion or reasoning for the conclusion. In light of the pertinent evidence above, the Board finds that service connection is not warranted for bilateral hand, elbows, wrists, or foot disabilities, claimed as generalized joint pain and/or osteoarthritis. As discussed above, the medical and lay evidence of record, indicate that with exception to current service-connected disabilities of bilateral thumb strain, bilateral carpal tunnel syndrome, and bilateral radiculopathy of the upper extremities, the Veteran does have pain on motion and limited movement as noted on examination, but these symptoms have not been attributed to disease or injury incurred in service. Following examination and normal x-ray findings, the VA examiner's did not find that that the Veteran's current joint pain of the bilateral hands, elbows, wrists, and feet were attributable to an underlying disorder, other than service-connected bilateral carpal tunnel syndrome and thumb strain, or that the Veteran's in-service complaints of joint pain were the early manifestations of any diagnosed disability of the joints, consistent with the x-rays identifying no osteoarthritis. Instead as discussed above, the September 2007 VA examiner diagnosed bilateral elbow pain, heat/cold tolerance of the bilateral hands, left hand injury, resolved, arthralgia of all major joints, and residuals of bilateral carpal tunnel releases and mild generalized joint pain with repetitive motion but concluded no clinical diagnosis of a chronic condition was found as far as objective evidence of arthritis or other musculoskeletal disability. The Board has considered that the 2013 examiner check the box indicating that the claimed bilateral foot disability was at least as likely as not incurred or caused by the claimed in-service injury, event, or illness. The rational was that " the veteran does not actually have the condition for which he was diagnosed during active duty and he is aware of that. However he did have pain in his forefoot which he describes as the same as during active duty and pain is modified with orthotics and/or proper footwear." However, to the subsequent 2014 medical opinion is more probative as it is supported by better reasoning. Given the negative findings for osteoarthritis of the bilateral hands, elbows, wrists, and feet, to include no diagnoses of plantar fasciitis and Morton's neuroma of the feet in service, and weighing the Veteran's reports of symptomatology with the September 2007, December 2009, and January 2013 VA examination reports, and the May 2014 and May 2016 VA medical opinions indicating no diagnosis of osteoarthritis, the Board finds the reasoned opinions of these examiners, who examined the Veteran and based their findings and opinions on the evidence of record to include the Veteran's reported history, and objective evidence that there are symptoms causing impairment such as pain as probative evidence against the claims. As discussed above, VA examiner's determined there was mild generalized joint pain with repetitive motion but determined no clinical diagnosis of a chronic condition was found as far as objective evidence of arthritis or other musculoskeletal disability. In contrast, in a November 2017 statement from Dr. P.A.B., who provided a nexus opinion that based on recent review of the Veteran's claims file and his reported medical history, bilateral hand, bilateral wrist pain, and shoulder pain are due to osteoarthritis caused by overuse during the Veteran's military service and his responsibilities working in planes. While Dr. B's report included that that clinician reviewed the Veteran's claims file, the November 2017 opinion did not include consideration of other factors to include his service-connected disabilities, nor did he explain the reasons for his conclusions. Thus, the November 2017 opinion is of little probative weight as the clinician did not provide a rationale in support of his opinion to include an explanation of x-rays, which identified normal joints without arthritis. As noted above, an adequate medical opinion must be based on accurate facts and history and must provide a rationale for its conclusions. Nieves-Rodriguez, 22 Vet. App. at 300. Review of the claims folder may heighten the probative value of a medical opinion, as the claims folder generally contains all documents associated with a Veteran's disability claim, such as medical treatment and examination reports and opinions, service records, and statements from the Veteran and possibly other lay witnesses. Id. at 303. However, to the extent that the November 2017 private opinion is an opinion linking joint disability with service, or, for that matter, that the Veteran has had osteoarthritis of the bilateral hands, elbows, wrists, and feet during the course of the current claim and appeal, Dr. B. did not provide any rationale for this opinion. Thus, the opinion has very low probative value. Respecting the Veteran's claims of generalized joint pain of the bilateral hands, elbows, wrists, and feet, the Board also acknowledges the September 2007 VA examiner's diagnosis of generalized joint pain and arthralgia of the joints. The Board reflects that the Court held that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection can be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), dismissed in part, vacated in part on other grounds sub. nom. Sanchez-Benitez v. Principi, 259 F.3d 1356, 1362 (Fed. Cir. 2001). Consequently, insofar as the Veteran has claimed bilateral hands, elbows, wrists, and feet pain, service connection cannot be awarded. In light of the foregoing, the Board finds that service connection for bilateral plantar fasciitis and Morten's neuroma is not warranted. The Board acknowledges the August 2008 diagnoses of plantar fasciitis and Morton's neuroma but finds the well-reasoned opinions of the VA examiners more probative than that of the August 2008 practitioner. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The Board has considered the Veteran's testimony and the testimony of the Veteran's wife regarding ongoing joint pain precipitated by repetitive motion. The Veteran's wife explained she has observed the Veteran's symptoms of pain and that the Veteran continues to wear braces on his wrists to treat bilateral carpal tunnel. She also described the pain he experienced during VA examinations due to painful motion as she described her conversation with the Veteran following VA examination of the joints. Additionally, the Board has considered the Veteran's statement that the examinations provided were inadequate. Specifically, in the March 2009 VA Form 9, Appeal to Board of Veterans' Appeals, the Veteran reported that his joint and neurology examinations did not include adequate examination of the hands, joint injury, or range of motion testing, asserting that joint impairment was not adequately observed and recorded. Further, the Board has also considered the Veteran's testimony during the Board hearing that he did not seek medical treatment in service for his bilateral elbow pain because it was considered standard practice to seek treatment from the flight surgeons only when it was necessary. The Veteran testified that as noted on his separation physical, the examiner opined that he had issues with his elbows. However, the Veteran explained that the examiner told him that they were "trying to get as many troops out the door with the exit physicals because these guys are coming back from Afghanistan, Iraq, want to get out, so we'll just sign you off, send you on." Additionally, the Board has considered the August 2009 statement of the Veteran's friend, Lt. Col. A.E.T. describing his knowledge of the Veteran's symptoms during service as associated with his military duties. When addressing a claim on the merits, the Board has an obligation to evaluate the credibility of evidence and to assign probative weight to competent evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (recognizing the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence"). In assessing the Veteran's credibility regarding his claims for joint pain and osteoarthritis, the Board looks to the consistency of his statements and clinical histories. Here, the record shows there is no current disability associated with the impairment of pain. In this regard, the Board is not rejecting the Veteran's reports of symptoms whether continuous or otherwise, as discussed above, the service treatment records include several reports of joint pain and document no clinical disability related to pain of the elbows, or the hands, other than related to service-connected bilateral thumb strain; and pain in the wrists, other than related to service-connected bilateral carpal tunnel syndrome but do not reflect the presence of objective evidence of arthritis or other musculoskeletal disability. The Veteran's May 2007 separation exam report notes the examiner acknowledged reports of pain and osteoarthritis and gave a normal clinical evaluation with regard to any relevant system or anatomy on the report. As such, the Board has considered the Veteran's assertions, but finds that they provide no persuasive support for these claims. As to non-expert or lay opinions with regard to diagnoses or a relationship of a condition to service ("nexus"), whether such opinions are competent evidence depends on the question at issue and the particular facts of the case. Although it is error to categorically reject a non-expert nexus opinion, not all questions of nexus are subject to non-expert opinion. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Whether a layperson is competent to provide a nexus opinion depends on the facts of the particular case. In Davidson, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) drew from its earlier decision in Jandreau v. Nicholson to explain its holding. Id. In that earlier decision, the Federal Circuit addressed the competency of lay diagnoses, stating as follows: "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Federal Circuit provided an example, stating that a layperson would be competent to identify a simple condition such as a broken leg, but not competent to provide evidence as to a more complex medical question such as a form of cancer. Id. at n.4. Also of note is that the Veterans Court has explained that non-expert witnesses are competent to report that which they have observed with their own senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Taking Davidson, Jandreau, and Layno together, leads the Board to the conclusion that the complexity of the question and whether a nexus opinion could be rendered based on personal observation are factors in determining whether a non-expert nexus opinion or diagnosis is competent evidence. A review of the record evidence shows there is no indication that the Veteran has medical expertise. Whether a specific incident in service nearly 10 years ago of joint pain related to the musculoskeletal system leads to specific disability, is not a simple question subject to non-expert opinion evidence. Thus, the Veteran's reported history, and the statements of the Veteran's wife and friend, when considered with the medical evidence of record, and in the context of the record, as a whole, is more probative than the Veteran's general lay statements. Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). In conclusion, the preponderance of the evidence is against the claims, and they are, therefore, denied. In arriving at the decision to deny the claims, the Board has considered the applicability of the benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107(b). However, as there is not an approximate balance of evidence, that rule is not applicable in this case. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). III. Increased Ratings Facial Nerve Impairment, Residuals of Bell 's palsy Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. 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. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). The Veteran's service-connected left side facial cranial nerve impairment is evaluated as 10 percent disabling effective August 1, 2007. See 38 C.F.R. § 4.124a, DC 8307 (2017). DC 8307 provides a 10 percent rating for incomplete moderate paralysis of the fifth (trigeminal) cranial nerve. A 20 percent rating is assigned for severe incomplete paralysis of the fifth (trigeminal) cranial nerve. A maximum 30 percent rating is assigned for complete paralysis of the fifth (trigeminal) cranial nerve. See 38 C.F.R. § 4.124a, DC 8307 (2017). Additionally, as discussed in detail below, a noncompensable rating has been in effect for dysphagia (with mild difficulty of swallowing associated with headaches, residuals of Bell's palsy) throughout the appeal period. The Veteran's disability is rated pursuant to DC 8210. By way of background, in a February 2007 rating decision the RO granted service connection for residuals of Bell's palsy to include headaches effective August 1, 2007 and assigned an evaluation of 10 percent. In an August 2014 rating decision the RO granted service connection for left facial nerve impairment residuals of bell's palsy, effective August 1, 2007 (the date following discharge from active service), and assigned a 10 percent disability rating and also increased the disability rating for headaches, residuals of Bell's palsy, currently 10 percent disabling to 50 percent effective August 1, 2007. Additionally, the August 2014 rating decision granted an earlier effective date for service connection for dysphagia, with mild difficulty swallowing associated with residuals of Bell's palsy, effective August 6, 2009. Notably, a May 2012 rating decision initially granted a noncompensable rating for service connection, effective August 7, 2009. Turning to the evidence, during the Board hearing, the Veteran described symptoms of his condition as numbness through the cheek or paralysis inside the cheek down through the throat, with dysphagia due to this paralysis. He reported shooting, sharp, zapping pains through the jawline described as feeling like electricity, resulting in biting the inside of his mouth explaining that there is no muscle to pull it back out. He explained that his cheek essentially drops and that occasionally he is unable to breathe out of the left nostril. He also wears breath right strips and Nasonex prescribed by his VA practitioner to help open airway passages explaining that the muscles essentially allowing the face to drop. The Veteran's wife affirmed his symptoms. The Veteran was afforded VA examinations in September 2007, March 2010, and January 2013. A September 2007 general medical examination report notes the Veteran's diagnosis of Bell's palsy manifested by symptoms of chewing and swallowing difficulty in May 2005. The examiner diagnosed residuals of Bell's palsy noting that the condition mildly impacts usual daily activities to include traveling, exercise, shopping, and recreational activities, as well as a moderate impact on sports activity. On VA cranial nerve examination in March 2010, the Veteran endorsed symptoms of facial weakness and swallowing trouble. He reported facial weakness had improved however he had mild persistent facial weakness as well as trouble swallowing almost anything. Mouth and throat symptoms included change in taste and mild difficulty swallowing. On examination, facial symptoms were noted as mild sensation of lancinating or electric shock pain, mild involuntary painless facial twitching or spasm, and mild weakness or paralysis of facial muscles. Sensory examination (fifth cranial nerve) of the forehead was normal and there was decreased sensation of the left cheek and chin. Light touch was normal and motor examination was also normal. Symptoms of the seventh cranial nerve (facial nerve) were normal with exception of left side hyperacusis determined to be of mild severity. There were no symptoms affecting cranial nerves 9 (glossopharyngeal nerve), 10 (vagus nerve) and 12 (hypoglossal nerve). The examiner diagnosed Bell's palsy with swallowing trouble noting that the Veteran was evaluated by barium study/speech therapy, which identified normal oral stage of swallowing. The pharyngeal stage was noted as mild-moderately impaired characterized by reduced base of tongue excursion on the left side, determined as residuals of Bell's palsy. The examiner concluded the Veteran had minimally-disabling swallowing trouble. On VA examination in January 2013, the Veteran reported that due to residuals of left side facial Bell's palsy, he continues to bite the inside of his mouth. He is on a regular diet with no liquid restriction due to swallowing issues but must ensure to have liquid with meals. The resulting examination report indicates the cranial nerves affected include the seventh cranial nerve (facial nerve) manifested by constant pain that at times is excruciating. The pain was in the lower face, left side and mild in severity as well as in the mid-face, left side. There was mild paresthesias and/or dysesthesias of the left upper face, eye and/or forehead; left mid-face; left lower face; and left side of the mouth and throat. There was moderate numbness of the left lower face, left mid-face, and left side of the mouth and throat. There was also moderate difficulty chewing and swallowing, mild difficulty speaking, and mild increased salivation. Muscle strength of all cranial nerves were normal to include cranial nerve V (motor: muscles of mastication; clench jaw, palpate masseter, and temporalis); cranial nerve XII (upper portion of face); cranial nerve IX, X (motor: swallow, cough, palate elevation); cranial nerve XI (motor: trapezius, sternocleidomastoid; shoulder shrug, turn head against resistance); and cranial nerve XII (motor: protrude tongue, move tongue from side to side). Sensory examination to light touch for facial sensation was normal. The examiner concluded that there was moderate incomplete paralysis of the seventh cranial nerve and the condition did not impact the Veteran's employment ability. VA treatment records during the appellate term are consistent with these findings. The Board finds that the preponderance of the evidence is against assigning an initial rating greater than 10 percent for any period of the appellate term for left side facial cranial nerve impairment. The Veteran contends that these disabilities are both more disabling than currently evaluated. The record evidence does not support these assertions. As noted above, the most probative evidence shows mild incomplete paralysis of the seventh cranial nerve (muscles of facial expression). Specifically, VA cranial nerve examination in March 2010 showed no findings, signs, or symptoms affecting cranial nerves 5 or 9-12 which control the upper face, eye, and/or forehead, mid-face, and lower face, with exception of decreased sensation of the left cheek and chin and mild severity left side hyperacusis. Physical examination in January 2013 showed moderate incomplete paralysis of the seventh cranial nerve (muscles of facial expression), left side; and mild paresthesias and/or dysesthesias of the left upper face, eye and/or forehead; left mid-face; left lower face; and left side of the mouth and throat. There was also moderate numbness of the left lower face, left mid-face, and left side of the mouth and throat. The examiner concluded that there was moderate incomplete paralysis of the seventh cranial nerve. The record evidence suggests that, throughout the appeal period, the Veteran has experienced, at worst, moderate incomplete paralysis of the seventh (facial) cranial nerve on the left side of his face (i.e., a 10 percent rating under DC 8307). See 38 C.F.R. § 4.124a, DC 8307 (2017). The Veteran has not identified or submitted any evidence to the contrary, which demonstrates that he experiences at least incomplete severe paralysis of the seventh (facial) cranial nerve (i.e., a 20 percent rating under DC 8307) such that a disability rating greater than 10 percent is warranted for the Veteran's service-connected left side facial cranial nerve impairment. Thus, the Board finds that the criteria for an initial rating greater than 10 percent, for left side facial cranial nerve impairment have not been met at any period during the appellate term. Finally, a noncompensable rating has been in effect for dysphagia (with mild difficulty of swallowing associated with residuals of Bell's palsy) throughout the appeal period. See DC 8210. As discussed in the pertinent evidence above, on VA examination in March 2010 the Veteran reported mild persistent facial weakness as well as trouble swallowing almost anything. The examiner diagnosed Bell's palsy with swallowing trouble noting that the Veteran was evaluated by barium study/speech therapy, which identified normal oral stage of swallowing. The pharyngeal stage was noted as mild-moderately impaired characterized by reduced base of tongue excursion on the left side. The examiner concluded the Veteran had minimally-disabling swallowing trouble and is likely a residual of Bell's palsy. In January 2013, the examiner determined there was moderate difficulty chewing and swallowing, and mild difficulty speaking, with mild increased salivation. The examiner concluded that the tenth cranial nerve was normal. Under DC 8210, paralysis of the tenth cranial nerve is rated 50 percent if complete, 30 percent if incomplete but severe, and 10 percent if incomplete but moderate. A corresponding Note indicates that evaluation is dependent upon the extent of sensory and motor loss to organs of voice, respiration, pharynx, stomach and heart. See 38 C.F.R. § 4.124a, DC 8210. The Board further notes that in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are met. C.F.R. § 4.31. The Board acknowledges the testimony of the Veteran and his wife during the Board hearing. The Veteran described symptoms of his condition as a numbness through the cheek or paralysis inside the cheek down through the throat, with dysphagia due to this paralysis. The Board has also considered the Veteran's reported symptoms as documented on VA examination and during treatment. The Veteran is competent to so state, but his opinions must be weighed against the other evidence of record. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). With respect to the Veteran's reported history, under certain circumstances, lay statements may be sufficient for disability claims by establishing the occurrence of lay-observable events, the presence of disability, or symptoms of disability that are susceptible to lay observation. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran, his wife, and the Veteran's friend are competent to testify to factually observable injuries and treatment, the timing of the observable symptoms of his disabilities, and receipt of medical treatment because these are observable by an individual's own senses and within the realm of knowledge of a lay person. Id. These reports must be considered with the entire record evidence. However, the Board finds the specific, reasoned opinions of the VA examiners, and the objective evidence of the trained medical professionals, who reviewed the Veteran's claims file and examined him, to be of greater probative weight than the more general lay assertions. Based on the weight of the lay and medical evidence of record, the Board finds that no more than mild symptoms have been demonstrated throughout the appeal process. Thus, a compensable rating is not warranted. For all the foregoing reasons, the Board finds that, the preponderance of the evidence is against entitlement to higher disability ratings at any time during the appellate term and there is no basis for further staged rating for the Veteran's left facial nerve impairment and dysphagia, with mild difficulty of swallowing, as a residual of Bell's palsy, pursuant to Hart, and that the claim for higher rating is not warranted, and must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against assignment of any higher rating for the right knee, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). IV. Extraschedular The Board has considered whether referral for an extraschedular rating is warranted in this case. As discussed below, and in accord with the Secretary's concession at oral argument, the Board holds that the availability of higher schedular ratings plays no role in an extraschedular analysis and that it is inappropriate for the Board to deny extraschedular referral on this basis. In this case, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). Neither the facts of the case nor the Veteran's allegations raise the issue of extraschedular consideration. Thus, no analysis is required. See Yancy v. McDonald, 27 Vet. App. 484, 494 (2016) (holding that an extraschedular analysis is not warranted where it is not "specifically sought by the claimant nor reasonably raised by the facts found by the Board") (citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007). See also Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (explaining that the Board had no obligation to analyze whether referral is warranted for extraschedular consideration if an extraschedular rating is not specifically sought by the claimant or reasonably raised by the facts found by the Board). TDIU The Veteran seeks a TDIU related to his service-connected headache disability. The Board recognizes that a claim for a total rating based on individual unemployability (TDIU) may be raised as a separate claim, or in the context of an initial rating or a claim for an increase. See Rice v. Shinseki, 22 Vet. App. 447, 452-53 (2009). Entitlement to TDIU requires the presence of impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by any nonservice-connected disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (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). 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. The service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue will be addressed in both instances. 38 C.F.R. § 4.16(a), (b). 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). If a veteran's disabilities do not meet the objective combined rating percentage criteria of 38 C.F.R. § 4.16(a), it then becomes necessary to consider whether the criteria for referral for extraschedular consideration are met under 38 C.F.R. § 4.16(b) criteria. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Submission to the Director, Compensation and Pension Service, for extraschedular consideration is warranted in all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in C.F.R. § 4.16(a). 38 C.F.R. § 4.16(b). Individual unemployability must be determined without regard to any non-service-connected disabilities or a veteran's advancing age. 38 C.F.R.§§ 3.341(a), 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether a veteran can find employment. Id. at 361. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a veteran's favor. 38 C.F.R § 4.3. In Faust v. West, 13 Vet. App. 342 (2000), the Court defined "substantially gainful employment" as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran's earned annual income. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to a TDIU is whether a veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332(1991). In evaluating a veteran's employability, consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran has also been granted service connection for the following disabilities: depressive disorder, which has been evaluated as 70 percent disabling; headaches, residual of Bell's palsy, evaluated as 50 percent disabling; radiculopathy right upper extremity with residuals, carpal tunnel syndrome right wrist, which has been evaluated as 40 percent disabling; radiculopathy left upper extremity with residuals, carpal tunnel syndrome left wrist, evaluated as 30 percent disabling; right shoulder impingement, evaluated as 20 percent disabling; left shoulder impingement, evaluated as 20 percent disabling; degenerative joint disease, evaluated as 20 percent disabling; osteoarthritis, right knee, evaluated as 10 percent disabling; left knee patellofemoral syndrome, evaluated as 10 percent disabling; left shoulder impingement, evaluated as 20 percent disabling; residuals, carpal tunnel syndrome right wrist, status-post release, evaluated as 10 percent disabling; residuals, carpal tunnel syndrome left wrist, status-post release, evaluated as 10 percent disabling erectile dysfunction, which is evaluated as non-compensably disabling; mechanical myofascial back pain, evaluated as 10 percent disabling; left hip strain (limitation of extension), evaluated as 10 percent disabling; right hip strain (limitation of extension), evaluated as 10 percent disabling; left hip strain, evaluated as 10 percent disabling; residuals of right ankle sprain, evaluated as 10 percent disabling; residuals of left ankle sprain, evaluated as 10 percent disabling; tinnitus, evaluated as 10 percent disabling; right thumb strain, evaluated as noncompensably disabling; left thumb strain, evaluated as noncompensably disabling; right hip strain (limitation of extension), evaluated as noncompensably disabling; left hip strain (limitation of extension), evaluated as noncompensably disabling; left shoulder scars, evaluated as noncompensably disabling; and dysphagia, evaluated as noncompensably disabling. In Bradley v. Peake, 22 Vet. App. 280 (2008), the Court held that, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of TDIU predicated on a single disability may form the basis for an award of special monthly compensation. Specifically, the Court found that TDIU was warranted in addition to a schedular 100 percent evaluation where the TDIU has been granted for a disability other than the disability for which a 100 percent rating was in effect. Under those circumstances, there was no "duplicate counting of disabilities." Bradley, 22 Vet. App. At 293. The remaining question, therefore, is whether any of the Veteran's service-connected disabilities render him unable to secure or follow a substantially gainful occupation. By way of background, a January 2015 rating decision denied entitlement to a TDIU based on a January 2015 VA examination for headaches indicating he is employable. In October 2014 and January 2017 the Veteran submitted VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability due to headaches. In these applications, he indicated that he could no longer maintain substantially gainful employment as a result of his service-connected headache disability. In the employment history, the Veteran indicated that following military service, he last worked in the field of pilot training for Chautauqua Airlines/Scott Bacon from June 2011 to July 2014. This is the only reported employment post-service discharge. The Veteran also provided the number of hours he worked during these periods, as well as his highest gross earnings per month during these years. According to the Veteran, he left this job as a result of his service-connected headache disability. He also noted to accommodate his headaches his employer allowed him to leave work early, travel one day in advance and depart from offsite training one day after others. Earlier records indicate that the Veteran's previous employment was military service, until he retired in 2007. During the Board hearing the Veteran reported his educational background includes a bachelor's degree from the Air Force Academy and a Master's Degree in Aeronautical Science. A January 2013 headaches DBQ indicates headache related to Bell's palsy diagnosed in 2011. The Veteran reported constant pain, and pulsating or throbbing head pain localized to one side of the head, typically the back of the head. He reported pain is precipitated by physical activity and alleviated with NSAID. There were no prostrating attacks of migraine headache pain. He did have prostrating attacks of non-migraine headache pain over the last several months occurring more frequently than once per month. Additional symptoms included sensitivity to sound. The examiner concluded that headache symptoms impact the Veteran's' ability to work noting his reports that he is unable to perform all of his duties due to headache pain. A January 2015 headaches DBQ indicates the examiner reviewed the claims file and interviewed the Veteran without examination. The resulting medical report indicates symptoms of constant pain, and pulsating or throbbing head pain localized to one side of the head, typically the left side occipital region. He reported pain is precipitated by physical activity. There was also constant sensitivity to light and sound. The DBQ indicates there was prostrating attacks of headache pain occurring once every month and the disability impacts the Veteran's ability to work concluding that the condition would present mild impairment for a sedentary and physical job in that he would have difficulty concentrating and focusing due to headache pain as well as miss several days from work due to severe headache pain. An August 2016 headache VA-contracted examination report notes the Veteran's reports of constant head pain from the left occiput forward to the crown of the head as well as ongoing depression over the condition and functional limitation. (Notably, service connection is established for depression.) Symptoms included constant headache pain, a squeezing pain with sharp needle like pains, and spikes of pain like an ice pick piercing the scalp lasting from 1 to 4 hours. There was also constant sensitivity to light and sound and prostrating a prolonged attacks of non-migraine headache pain occurring more frequently than once per month. The examiner concluded that the Veteran's headache condition impacted his ability to work in that he is unable to function due to pain. During the Board hearing he explained that he last worked 3 years ago. He explained his responsibilities included multiple tasks involving manual labor, which caused headaches. He explained that he required accommodations for rest and taking breaks to adapt because of ongoing pain. Despite such accommodations, to include resting in the car during a spike, the Veteran stated that was unable to maintain employment. The Veteran and his spouse further explained daily prostrating headaches resulting in two hours of bed rest daily, and difficulty sleeping because of headaches. The Veteran's wife described him as sleep deprived. He reported the same in a November 2015 statement in support of the claim. Additionally, an undated letter from VA nurse, A.B. on behalf of E.B., M.D., indicates that the Veteran is suffering from chronic headaches associated with Bell's palsy. The clinician explains that the Veteran has been treated with multiple methods to alleviate headache pain, to include multiple medications and treatment at the neurology and interventional pain clinic without much help. Despite exhausting treatment options, the Veteran's pain persists. The clinician further explained after many different trials of treatment that failed he was eventually released from the clinic. It was noted that he continues to have chronic headaches daily without relief from any prescribed treatment and this makes it difficult for him to work and perform daily tasks. After a review of the evidence of record, the Board finds, resolving reasonable doubt as mandated by law (38 U.S.C. § 5107; 38 C.F.R. § 3.102), that the evidence supports the conclusion that the Veteran's service-connected headache disability prevents him from securing and following a substantially gainful employment. In reaching this determination, the Board notes that during the course of this appeal the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that determination of whether a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the RO. See Geib v. Shinseki¸733 F.3d 1350 (Fed. Cir. 2013). In light of the treatment records and medical opinions provided, the Board finds that, considering the record as a whole, the Veteran's claim for a TDIU is warranted. Of particular importance to the Board in this matter, are the Veteran's assertions particularly that despite accommodations provided by his employer, he was unable to maintain employment tasks due to daily headache pain. Additionally, the undated letter from A.B., VA nurse describing the exhausted trials of treatment that proved unsuccessful, as well as the VA examination reports, which address the severity of the symptoms associated with the Veteran's headache disability. In light of this evidence, and given his individual work experience, training and education, the Board finds that the evidence shows he is entitled to an award of a TDIU rating based on his service-connected headache disability. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). Thus, the Veteran's claim for entitlement to a TDIU is granted. Entitlement to SMC at the Housebound Rate The Board must consider entitlement to SMC if raised by the rating issue on appeal. Akles v. Derwinski, 1 Vet. App. 118 (1991) SMC at the (s) rate is payable if a veteran has a single service-connected disability rated as 100 percent and: (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C.§ 1114 (s); 38 C.F.R. § 3.350 (i). For the purpose of meeting the first criterion (a single service-connected disability rated at 100 percent), ratings of 100 percent may be based on any of the following grants of a total rating: on a schedular basis; on an extraschedular basis; on the basis of a TDIU if granted for a single disability; or, on the basis of a temporary total rating. Subsection 1114(s) housebound benefits are not available to a veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. See Guerra v. Shinseki, 642 F.3d 1046 (Fed. Cir. 2011). However, in Bradley v. Peake, 22 Vet. App. 280, 293 (2008), the Court held that a TDIU satisfies the total (100 percent) rating requirement if the TDIU evaluation was, or can be, predicated upon a single disability and there exists additional disability or disabilities independently ratable at 60 percent or more, for purposes of entitlement to special monthly compensation for a housebound rating. In other words, 38 U.S.C. § 1114 (s) for housebound benefits does not limit "a service-connected disability rated as total" to only a schedular rating of 100 percent. Id. A TDIU rating based on a single disability is permitted to satisfy the statutory requirement of a total rating. Id. Nonetheless, the TDIU rating based on a single disability that satisfies the total (100 percent) rating requirement must be separate and distinct from the additional disability or disabilities independently ratable at 60 percent or more for purposes of housebound benefits. Id. In addition, the Bradley decision also stated that the decision to treat multiple disabilities as one under 38 C.F.R. § 4.16(a) was specifically limited to TDIU ratings. That is, a TDIU rating based on multiple service-connected disabilities does not satisfy the criteria for one total disability in considering entitlement to housebound benefits under 38 U.S.C. § 1114(s). Id. at 290-91. The Court reiterated this interpretation with its holding in Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2010) ("The Court today holds that a TDIU rating that is based on multiple disabilities cannot satisfy the section 1114(s) requirements of 'a service-connected disability' because that requirement must be met by a single disability."). As noted above, the Board awarded a TDIU as a result of the Veteran's service-connected headache disability. As such, the first element of entitlement to SMC at the (s) rate is shown. As discussed above, the Veteran has also been granted service connection for the following disabilities: depressive disorder, which has been evaluated as 70 percent disabling; radiculopathy right upper extremity with residuals, carpal tunnel syndrome right wrist, which has been evaluated as 40 percent disabling; radiculopathy left upper extremity with residuals, carpal tunnel syndrome left wrist, evaluated as 30 percent disabling; right shoulder impingement, evaluated as 20 percent disabling; left shoulder impingement, evaluated as 20 percent disabling; degenerative joint disease, evaluated as 20 percent disabling; osteoarthritis, right knee, evaluated as 10 percent disabling; left knee patellofemoral syndrome, evaluated as 10 percent disabling; left shoulder impingement, evaluated as 20 percent disabling; residuals, carpal tunnel syndrome right wrist, status-post release, evaluated as 10 percent disabling; residuals, carpal tunnel syndrome left wrist, status-post release, evaluated as 10 percent disabling erectile dysfunction, which is evaluated as non-compensably disabling; mechanical myofascial back pain, evaluated as 10 percent disabling; left hip strain (limitation of extension), evaluated as 10 percent disabling; right hip strain (limitation of extension), evaluated as 10 percent disabling; left hip strain, evaluated as 10 percent disabling; residuals of right ankle sprain, evaluated as 10 percent disabling; residuals of left ankle sprain, evaluated as 10 percent disabling; tinnitus, evaluated as 10 percent disabling; right thumb strain, evaluated as noncompensably disabling; left thumb strain, evaluated as noncompensably disabling; right hip strain (limitation of extension), evaluated as noncompensably disabling; left hip strain (limitation of extension), evaluated as noncompensably disabling; left shoulder scars, evaluated as noncompensably disabling; and dysphagia, evaluated as noncompensably disabling. Here, his disabilities other than the headache condition combine to more than 60 percent. Thus, SMC at the rate specified at 38 U.S.C.A. § 1114 (s) must be granted. ORDER Service connection for bilateral hand disability, claimed as generalized joint pain and/or osteoarthritis, is denied. Service connection for bilateral elbow disability, claimed as generalized joint pain and/or osteoarthritis, is denied. Service connection for bilateral wrist disability, claimed as generalized joint pain and/or osteoarthritis, is denied. Service connection for bilateral foot disability, claimed as generalized joint pain and/or osteoarthritis, is denied. An increased disability rating in excess of 10 percent for left facial nerve impairment, as a residual of Bell's palsy, is denied. A compensable rating for dysphagia, with mild difficulty of swallowing, as a residual of Bell's palsy, is denied. A total disability rating based on individual unemployability due to the service-connected headache disability is granted, subject to the applicable laws and regulations governing the payment of monetary benefits. SMC at the 38 U.S.C. § 1114 (s) rate is granted, subject to the regulations pertaining to the payment of monetary benefits. ______________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs