Citation Nr: 18150223 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 16-39 413 DATE: November 14, 2018 ORDER An effective date of December 16, 2011, but no earlier, for the award of service connection for post-traumatic stress disorder (PTSD) is granted. An effective date of December 16, 2011, but no earlier, for the award of service connection for spondylosis with degenerative disc disease (DDD) is granted. An effective date of December 16, 2011, but no earlier, for the award of service connection for a right shoulder strain is granted. An effective date of December 16, 2011, but no earlier, for the award of service connection for a pilonidal cyst is granted. A rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is denied. A rating in excess of 10 percent for spondylosis with DDD prior to June 11, 2015, is denied. A rating in excess of 20 percent for spondylosis with DDD since June 11, 2015, is denied. A compensable rating for a pilonidal cyst is denied. A rating in excess of 10 percent for a cervical strain is denied. Service connection for a traumatic brain injury (TBI) is granted. Service connection for a tremor disorder is denied. Service connection for a temporomandibular joint (TMJ) disorder is denied. Service connection for a bilateral hip disorder is denied. Service connection for hypertension is denied. A total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is granted. REMANDED A rating in excess of 10 percent for a right shoulder strain. Service connection for blurry vision. Service connection for bilateral hearing loss. Service connection for migraine headaches. FINDINGS OF FACT 1. The Veteran had active service from August 2008 to December 2011 and from September 2012 to February 2015. 2. In March 2012, within months of discharged from the first period of service, VA received the Veteran’s claim of service connection for PTSD, a back disorder, a right shoulder disorder, and a pilonidal cyst. 3. For the entire period on appeal, PTSD has been manifested by subjective complaints of insomnia, irritability, flashbacks, nightmares, hypervigilance, avoidance of crowds, short-term memory difficulties, auditory hallucinations, and thoughts of suicide; objective findings include persistent hallucinations, suicidal ideations with no plan or intent, a linear, logical, organized, and goal directed thought process, appropriate hygiene, normal, clear, and fluent speech, intact recent and remote memory, and orientation to person, place, and time. 4. Prior to June 11, 2015, a low back disability was manifested by subjective complaints of constant, sharp, aching, and stabbing lower back pain; objective findings included forward flexion to 90 degrees, a combined range of motion measured at 240 degrees, no guarding or muscle spasms, no ankylosis, and no IVDS. 5. Since June 11, 2015, a low back disability has been manifested by subjective complaints of daily back pain aggravated by standing for longer than 30 minutes; objective findings include forward flexion to 60 degrees, a combined range of motion of 210 degrees, no guarding or muscle spasms, no ankylosis, and IVDS without periods of required bed rest prescribed by a physician. 6. For the entire period on appeal, a pilonidal cyst has been manifested by subjective complaints of a recurring pilonidal cyst and periods during which the cyst drained and was painful; objective findings include no scarring or disfigurement, no benign or malignant skin neoplasms, and no systemic manifestations due to skin diseases. 7. For the entire period on appeal, a cervical strain has been manifested by subjective complaints of neck stiffness; objective findings include forward flexion to 45 degrees, a combined range of motion of 340 degrees, no guarding or muscle spasms, and no IVDS. 8. The Veteran’s TBI is etiologically related to service. 9. A tremor disorder, TMJ, a bilateral hip disorder, and hypertension have not been shown. 10. The Veteran is unemployable due to service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to an effective date of December 16, 2011, but no earlier, for the award of service connection for PTSD have been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.4, 3.31, 3.401, 3.654 (2017). 2. The criteria for entitlement to an effective date of December 16, 2011, but no earlier, for the award of service connection for spondylosis with DDD have been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.4, 3.31, 3.401, 3.654 (2017). 3. The criteria for entitlement to an effective date of December 16, 2011, but no earlier, for the grant of service connection for a right shoulder sprain have been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.4, 3.31, 3.401, 3.654 (2017). 4. The criteria for entitlement to an effective date of December 16, 2011, but no earlier, for the grant of service connection for a pilonidal cyst have been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.4, 3.31, 3.401, 3.654 (2017). 5. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.130, Diagnostic Code (DC) 9411 (2017). 6. The criteria for a rating in excess of 10 percent prior to June 11, 2015, for spondylosis with DDD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, DCs 5242, 5243 (2017). 7. The criteria for a rating in excess of 20 percent since June 11, 2015, for spondylosis with DDD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, DCs 5242, 5243 (2017). 8. The criteria for a compensable rating for a pilonidal cyst have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.118, DCs 7800-7805, 7819 (2017). 9. The criteria for a rating in excess of 10 percent for a cervical strain have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, DCs 5237, 5243 (2017). 10. Resolving reasonable doubt in his favor, a TBI was incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310 (2017). 11. A tremor disorder was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310 (2017). 12. A TMJ disorder was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310 (2017). 13. A bilateral hip disorder was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310 (2017). 14. Hypertension was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310 (2017). 15. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5103(a), 5103A (2012); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.15, 4.16, 4.18, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Claims for an Earlier Effective Date Under governing law, the effective date of an award of disability compensation, in conjunction with a grant of entitlement to service connection, shall be the day following separation from active service or the date entitlement arose, if the claim is received within one year of separation from service; otherwise, the effective date shall be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2). The Veteran had active service between August 2008 and December 15, 2011 and between September 12, 2012 and February 27, 2015. A review of the record reveals that he submitted claims for PTSD, a right shoulder condition, a back condition, and a cyst on March 28, 2012. On October 2, 2013, the RO notified him that, as he had returned to active service, development of his claims would be suspended until his ultimate separation from service. He was subsequently granted service connection for PTSD, spondylosis with DDD, a right shoulder strain, and a pilonidal cyst and an effective date of February 28, 2015 was assigned, a date that corresponds to the day after separation from his second period of active duty. Under the law, compensation pay will be discontinued when a veteran receives active service pay, effective the day preceding reentrance into active duty status, and that staged ratings can be assigned for separate periods based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007); 38 C.F.R. § 3.654 (2017). In light of the above, service connection for PTSD, spondylosis with degenerative disc disease, a right shoulder strain, and a pilonidal cyst is warranted, effective between December 16, 2011 (the date after separation from the first period of active duty) and September 11, 2011 (one day prior to the beginning of his second period of active duty), but no earlier. As he was on active duty until February 27, 2015, benefits are again warranted beginning February 28, 2015. Accordingly, the Veteran’s claims for service connection for PTSD, spondylosis with degenerative disc disease, a right shoulder strain, and a pilonidal cyst were received in March 2012, three months after his initial separation from service. Therefore, service connection is warranted from the day after his initial separation from service, December 16, 2011. To this extent, the appeal is granted. Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 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. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. PTSD PTSD is evaluated under a General Rating Formula for Mental Disorders (“General Rating Formula”). Under the General Rating Formula, a 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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, and effectively, impaired impulse control (such as an 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), and an inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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 daily hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. The symptoms listed under the rating criteria are meant to be examples of symptoms that would warrant the rating, but they are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence shows that a veteran experiences symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Furthermore, the rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). In an August 2014 VA examination, the Veteran reported receiving treatment for PTSD and going home after his daily sessions. He said that at home, he interacted with his wife, son, and dog, and played video games. He noted that he had previously been hospitalized for homicidal ideation. He said that he felt his anger was more under control but worried about working around people after separation from active service because he was easily angered and frustrated. The examiner found that the Veteran demonstrated symptoms of PTSD including a depressed mood, anxiety, suspiciousness, panic attacks occurring weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. He noted that the Veteran denied suicidal or homicidal ideations. In medical treatment notes between August 2014 and August 2016, the Veteran indicated that he continued to have insomnia, irritability, flashbacks, nightmares, hypervigilance and avoidance of crowds. Upon examination, his attention to hygiene was good, the rate and volume of his speech were normal, his thought process was normal, his thought content was logical, and he denied auditory or visual hallucinations. He was oriented to person, place, time, and situation and his memory was grossly intact. In August 2016 medical treatment notes, the Veteran reported experiencing a short-term memory impairment that impeded his ability to perform activities of daily living, and that he increasingly heard voices and experienced hallucinations of former friends degrading him, telling him to kill himself, and screaming that he doesn’t deserve to be alive. Upon examination, clinicians found him to be oriented to person, place, time, and situation. His thought continuity was clear and coherent, his thought content was within normal limits, and his memory was grossly intact. The clinicians noted that he had suicidal thoughts or feelings but no suicidal behavior. In an October 2016 medical treatment note, the Veteran reported struggling with suicidal ideations since before separation from service, that he had difficulty with his short-term memory, and that he struggled with hallucinations. He denied engaging in violent or self-injurious behavior. Upon examination, his speech was spontaneous with a normal rate, volume, prosody, and articulation and his thought process was logical, linear, and goal directed. The clinician found that his reported auditory hallucinations were dissociative episodes with PTSD, noted that his recent and remote memory were intact, found him to be oriented to person, place, and time, and observed that while he had chronic suicidal ideations, he had no plan or intent. In a December 2016 Disability Benefits Questionnaire (DBQ), a private clinician diagnosed PTSD and a related, overlapping TBI. The clinician noted that the Veteran’s PTSD was manifested by an occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and mood. Upon examination, the clinician found that as a result of his PTSD, the Veteran was unable to maintain healthy social relationships and had difficulty communicating and getting along with others, especially in work and social settings. The clinician checked every box identifying the PTSD in Criterion A, B, C, D, E, F, and nearly every box (26/30) with respect to symptoms. In a January 2017 medical treatment note, the Veteran reported that his auditory hallucinations were improved and he denied having suicidal ideations. A subsequent March 2017 medical treatment note found him to be oriented to person, place, time, and situation, his hygiene and dress to be adequate, his speech rate and volume normal, his thought content appropriate, and his thought process linear, logical, organized, and goal directed. He denied suicidal or homicidal ideations and did not note auditory or visual hallucinations. Based on the above, a 100 percent rating for PTSD is not warranted. In this regard, the weight of the evidence reflects that the Veteran experienced intermittent auditory hallucinations and suicidal ideations without plan or intent. However, his thought process was consistently linear, logical, organized, and goal directed, his hygiene was appropriate, and his speech was normal, clear, and fluent. Additionally, clinicians found that his recent and remote memory were intact and that he was oriented to person, place, and time. Accordingly, the medical evidence does not support a rating in excess of 70 percent for PTSD. Spondylosis with DDD The Veteran’s lumbar spine disability has been rated at 10 and 20 percent under DCs 5242 and 5243. The Board will consider all relevant diagnostic codes. In order to warrant a higher rating, the objective medical evidence must show the following: • forward flexion in the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees (20% under DC 5242); • the combined range of motion of the thoracolumbar spine not greater than 120 degrees (20% under DC 5242); • muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour (20% under DC 5242); • intervertebral disc syndrome (IVDS) with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20% under DC 5243); • forward flexion in the thoracolumbar spine of 30 degrees or less (40% under DC 5242); • favorable ankylosis of the entire thoracolumbar spine (40% under DC 5242); • IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months (40% under DC 5243). Rating Period Prior to June 11, 2015 In an August 2014 VA examination, the Veteran reported experiencing low back pain as a result of injuries suffered in an IED blast. He noted that flare-ups did not impact the function of his lumbar spine. Upon examination, the range of motion of his lumbar spine was found to be normal, including forward flexion to 90 degrees, extension to 30 degrees, left and right lateral flexion to 30 degrees each, and left and right lateral rotation to 30 degrees each. His combined range of motion was measured at 240 degrees. The examiner found that the Veteran had functional loss and impairment of his lumbar spine that manifested through pain on movement. He did not have localized tenderness or pain to palpation for joints of the lumbar spine, muscle spasms of the lumbar spine resulting in abnormal gait or abnormal spinal contour, or guarding of the lumbar spine resulting in abnormal gait or abnormal spinal contour. The Veteran did not have ankylosis of the spine, IVDS, or a thoracic vertebral fracture with a loss of 50 percent or more of height. Ultimately, the examiner diagnosed a lumbar strain. In subsequent medical treatment notes, the Veteran complained of constant, sharp, aching, and stabbing pain located in the middle of his lumbar spine that radiated occasionally into his legs and up to the scapular region. He reported that his pain was aggravated by movement and worsened by activity, bending, exercise, lifting, standing for prolonged periods, standing from a sitting position, turning, and twisting. A May 2015 clinician found that the range of motion of his lumbar spine was painfully restricted between 25 percent and 50 percent, but did not assess his forward flexion or measure his combined range of motion. Based on the above, a rating in excess of 10 percent prior to June 11, 2015, is not warranted. In this regard, flexion of the Veteran’s lumbar spine was measured at 90 degrees with a combined range of motion was measured at 240 degrees. The August 2014 VA examination further revealed that he did not have guarding or muscle spasms resulting in abnormal gait or spinal contour, ankylosis, or IVDS. Accordingly, a rating in excess of 10 percent prior to June 11, 2015 is not warranted and the appeal is denied to this extent. Rating Period since June 11, 2015 In a September 2015 VA examination, the Veteran described daily back pain with shooting back pain into his groin and both of his legs that increased when standing for longer than 30 minutes, and associated numbness in both legs. He did not report flare-ups or functional loss or impairment of his lumbar spine. Upon examination, his range of motion was measured as forward flexion to 60 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees each, and right and left lateral rotation to 30 degrees each. His combined range of motion was 210 degrees. The examiner found that the Veteran had radicular pain or signs and symptoms due to radiculopathy that manifested through mild constant pain, mild paresthesias or dysesthesias, and mild numbness in his bilateral lower extremities. However, he did not have guarding or muscle spasms of his lumbar spine or ankylosis. Additionally, while he had IVDS, he did not have any episodes of acute signs or symptoms due to IVDS that required bed rest prescribed by a physician over the 12 months prior to the examination. The examiner ultimately diagnosed a lumbar strain, lumbar DDD, lumbar stenosis, and lumbar IVDS, opining that the lumbar disability did not impact his ability to work. In subsequent medical treatment notes, the Veteran reinforced that his formerly intermittent back pain occurred daily. Most recently, a January 2017 clinician noted that the Veteran had functional active range of motion of his lumbar spine with no signs of pain. Based on the above, a rating in excess of 20 percent since June 11, 2015 is not warranted. In this regard, the September 2015 VA examination measured the Veteran’s forward flexion at 60 degrees and found that he had no ankylosis of the lumbar spine. Furthermore, while the examination diagnosed IVDS, it reported that he did not have any incapacitating episodes over the 12 months prior to the examination. Accordingly, the medical evidence does not support a rating in excess of 20 percent for spondylosis with DDD since June 11, 2015. Pilonidal Cyst The Veteran’s pilonidal cyst is rated under DC 7819. The Board will also consider all potentially relevant diagnostic codes. In order to warrant a compensable rating, the objective medical evidence must show: • A scar or other disfigurement of the head, face, or neck with one characteristic of disfigurement (10% under DC 7800); • A scar due to other causes not of the head, face, or neck that is deep and nonlinear and measures no more than 12 square inches (10% under DC 7801); • A scar not of the head, face, or neck, that is superficial and nonlinear and measures 144 square inches or greater (10% under DC 7802); or • One or two scars that are unstable or painful (10% under DC 7804). In an April 2015 VA examination, the Veteran reported that in 2011, he had a pilonidal cyst in his tailbone area removed, but that it flared up occasionally. He described how fluid seeped out during flare-ups that subsequently dried up and went away. He said that the cyst would be painful for the month until it completely dried up and went away. He noted that it got infected once and then resolved without antibiotics. The Veteran noted that his pilonidal cyst did not cause scarring or disfigurement of the head, face, or neck and did not result in benign or malignant skin neoplasms or in systemic manifestations due to skin diseases. He said that he was not treated with oral or topical medications or with non-oral or non-topical medications for his cyst in the 12 months prior to his examination. The examination revealed a dimple with surrounding granulation tissue at the most superior aspect of the midline of his intragluteal fold, but found no visible skin conditions, no benign or malignant neoplasms. Ultimately, the examiner diagnosed a pilonidal cyst and opined that it did not impact his ability to work. Based on the above, a compensable rating for a pilonidal cyst is not warranted. In this regard, the April 2015 VA examination found that the Veteran’s cyst did not cause scarring or disfigurement and did not result in benign or malignant skin neoplasms or in systemic manifestations due to skin diseases. Moreover, while the Veteran reported brief pain during periods when the cyst drained, he noted that the pain resolved itself when the cyst completely dried up. Accordingly, the medical evidence does not support a compensable rating. Cervical Strain The Veteran’s cervical strain has been rated under DCs 5237 and 5243. The Board will consider all relevant diagnostic codes. In order to warrant a higher rating, the objective medical evidence must show the following: • forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees (20% under DC 5237); • a combined range of motion of the cervical spine no greater than 170 degrees (20% under DC 5237); • muscle spasms or guarding severe enough to result in abnormal gait or abnormal spinal contour (20% under DC 5237); • IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20% under DC 5243). In a May 2015 medical treatment note, a clinician diagnosed mechanical neck pain. The clinician noted that the Veteran had full range of motion of his cervical spine with guarding and pain at the end range. In a subsequent September 2015 VA examination, the Veteran reported having neck stiffness 90 percent of the time. He did not report experiencing functional limitations or flare-ups of the cervical spine and did not report any treatment of his cervical spine since his discharge from service. Upon examination, range of motion of his cervical spine was found to be all normal and measured as follows: forward flexion to 45 degrees, extension to 45 degrees, right and left lateral flexion to 45 degrees each, and right and left lateral rotation to 80 degrees each. The combined range of motion of his cervical spine was measured at 340 degrees. The examination revealed that the Veteran did not have localized tenderness, guarding, or muscle spasms of the cervical spine, ankylosis of the cervical spine, or IVDS of the cervical spine. The examiner diagnosed a cervical strain and cervical DDD, opining that his cervical spine conditions did not impact his ability to work. Based on the above, a rating in excess of 10 percent is not warranted for a cervical strain. In this regard, the September 2015 VA examination measured the forward flexion of his cervical spine at 45 degrees and the combined range of motion of the cervical spine at 340 degrees. The examiner further found that the Veteran did not have guarding of the cervical spine, muscle spasms, or IVDS. Accordingly, the medical evidence does not support a rating in excess of 10 percent. With respect to the increased rating claims, the Board has considered the Veteran’s lay statements that his disabilities are worse. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, Layno v. Brown, 6 Vet. App. 465, 470 (1994), he is not competent to identify a specific level of disability of these disorders according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which these disabilities are evaluated. Moreover, as the examiners have the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disabilities and had sufficient facts and data on which to base the conclusions, the Board affords the medical opinions great probative value. As such, these records are more probative than the Veteran’s subjective complaints of increased symptomatology. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable and the appeals are denied. Service Connection Claims Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be granted on a presumptive basis for diseases listed in § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307.   TBI As an initial matter, the Veteran has been diagnosed with a TBI. Specifically, medical treatment notes in January 2017 diagnosed a mild TBI. Therefore, a current disorder has been shown and the first element of service connection has been met. The Veteran has argued that he incurred his disability while service in Afghanistan. Specifically, in an April 2016 statement, he reported that he was in a bomb explosion and ultimately got blown forward back into his vehicle. He said that the explosion blew up the back of his striker and resulted in him briefly passing out and having difficulty forming sentences. The DD 214 shows that he served in Afghanistan in designated imminent danger areas. Furthermore, a review of STRs reveals that in December 2011 and March 2015 treatment notes, he reported experiencing a blast or explosion from an IED, RPG, land mine, or grenade, and developing symptoms including being dazed, seeing stars, amnesia, a concussion, irritability, headaches, and sleep problems. In both December 2011 and March 2015, the clinician found the TBI screen to be positive. Therefore, an in-service injury has been shown and the second element of service connection has been met. As to nexus, the evidence is in equipoise. On the one hand, a review of the post-service medical treatment notes reveals that in a January 2017 medical treatment note, the Veteran reported multiple in-service exposures to explosion blasts. He recounted having multiple periods of disorientation, confusion and memory loss immediately after the event and said that since his deployment, his overall symptoms were worse. The clinician diagnosed a mild TBI and found that the history of his injury and course of clinical symptoms was consistent with a diagnosis of a TBI sustained during deployment. This evidence weighs in favor of the claim. On the other hand, an August 2014 VA examiner opined that the Veteran was not diagnosed with a TBI. The examiner observed that no substantial clinical findings were present to support the claimed TBI and, as a result, opined that the etiology of the Veteran’s symptoms could not be assessed without resorting to medical speculation. This evidence tends to weigh against the claim. Nonetheless, as there is evidence weighing both for and against the claim, it places the evidence at least in equipoise on the question of whether the Veteran’s TBI is more likely than not incurred in or caused by active service. For this reason, after resolving reasonable doubt in his favor, service connection for a TBI is warranted and the appeal is granted. Because the Board is granting service connection on a direct basis, all other theories of service connection are rendered moot. Tremor Disorder, TMJ Disorder, Bilateral Hip Disorder, and Hypertension For a disability to be service connected, it must be present at the time a claim for VA disability compensation is filed or during or contemporary to the pendency of the appeal. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The record does not show that the Veteran has a confirmed diagnosis of a tremor disorder, a TMJ disorder, a bilateral hip disorder, or hypertension. To that end, a series of August 2014 VA examinations found no evidence of a tremor disorder, TMJ disorder, bilateral hip disorder, or hypertension. Subsequently in July 2015 and November 2016 post-separation medical treatment notes, the Veteran denied having symptoms of a tremor disorder. Similarly, while he reported a TMJ condition in a September 2016 medical treatment note, the clinician found his left and right TMJs to be within normal limits. Additionally, in a January 2017 medical treatment note, the Veteran reported right shoulder and lower back pain; however, he did not report any other joint pain, and a clinician found that he had functional active range of motion in his lower extremities. Finally, the record shows that VA consistently monitored the Veteran’s blood pressure, but did not find it to be elevated to warrant a diagnosis of hypertension. With respect to all the service connection claims, the Board has considered lay statements offered by the Veteran regarding the severity and etiology of the disabilities discussed above. He is competent to report symptoms and describe his observations because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to offer opinions as to the etiology or severity of any current disorder due to the medical complexity of the matters involved. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Competent evidence has been provided by the medical personnel who have examined the Veteran during his current appeal and by service records obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to the lay statements that have been submitted. As noted above, service connection may only be granted for a current disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As there are no confirmed diagnoses of a tremor disorder, a TMJ disorder, or a bilateral hip disorder at any time during the pendency of the appeal, the medical evidence does not support service connection for a tremor disorder, a TMJ condition, or hypertension, and the appeals are denied to this extent. TDIU TDIU ratings may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there are sufficient additional service-connected disability ratings to bring the combined rating to 70 percent or more. 38 C.F.R §§ 3.340, 3.341, 4.16(a). Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). In evaluating a veteran’s employability, consideration may be given to his or her level of education, special training, and previous work experience in arriving at a conclusion, but not to age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.321(b), 4.16, 4.19. The mere fact that a claimant is unemployed or has difficulty obtaining employment is not sufficient. A high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. 38 C.F.R. § 4.16(a). For the purpose of one 60 percent or one 40 percent disability in combination, disabilities resulting from a common etiology or a single accident will be considered as one disability. 38 C.F.R. § 4.16(a). Even when the percentage requirements are not met, entitlement to a total rating, on an extraschedular basis, may nonetheless be granted in exceptional cases, when the veteran is unable to secure and maintain a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. §§ 3.321(b), 4.16(b). The Veteran is service connected for PTSD at 70 percent, spondylosis with DDD previously rated at 10 and now rated at 20 percent effective June 11, 2015, a cervical strain at 10 percent, tinnitus at 10 percent, a right shoulder strain at 10 percent, a corneal scar at 0 percent, a right shoulder scar at 0 percent, a pilonidal cyst at 0 percent, and a post-surgical right shoulder scar at 0 percent. The combined rating is 80 percent. Therefore, he meets the rating percentages of 38 C.F.R. § 4.16(a). The Veteran has reported that he was last able to work on June 26, 2014, at which time he became too disabled to work. A review of the record reveals that he has experience working in the wine industry and serving in the military. The record further reveals that he completed high school and attended college. In a series of August 2014 VA examinations, examiners diagnosed a lumbar strain, a cervical strain, a right shoulder strain, a corneal scar, blurry vision, recurrent tinnitus, and PTSD. The examiners opined that the Veteran’s right shoulder strain impacted his ability to work, explaining that his shoulder strain resulted in limited function and an inability to perform physical training requirements and that his eye condition. The examiners also remarked that recurrent tinnitus made it harder for the Veteran to hear other people and that as a result of his PTSD, he worried about his ability to work around people after his separation from service, as he was easily angered and frustrated. In a subsequent April 2015 VA examination, a pilonidal cyst was diagnosed and found to not have an impact on his ability to work. In April 2015, the Social Security Administration (SSA) found that the Veteran had a disability for social security purposes and was eligible to receive Social Security benefits. The SSA established that the disability began on June 26, 2014. In doing so, the SSA noted that the diagnoses that resulted in the disability included primarily anxiety-related disorders and secondarily affective disorders. The SSA noted that he claimed that his disability was the result of a right shoulder sprain and PTSD and found his claims to be credible. In a second April 2015 VA examination, the examiner diagnosed PTSD characterized by occupational and social impairments in most areas. The examiner noted that the Veteran wanted to work as a police officer, but was unable to do so because of the severity of his symptoms, for psychiatric reasons, and due to the inappropriateness of him carrying firearms. In a September 2015 VA addendum opinion, the examiner clarified that, while PTSD limited the Veteran’s occupational opportunities in law enforcement, he could pursue other fields of work as he was physically capable, alert, young, and intelligent. The examiner opined that over time, he had occupational potential that could result in some level of gainful employment. The Board notes the examiner clarified why the Veteran’s PTSD symptoms prevented him from working in the law enforcement field, but did not specifically identify the impact of his PTSD symptoms on his ability to pursue other fields of employment and did not provide a rationale as to why he would be able to obtain some level of gainful employment over time. Accordingly, with regard to the Veteran’s ability to obtain and maintain substantial gainful employment, the September 2015 addendum opinion is assigned lesser probative value. In a series of September 2015 VA examinations, examiners diagnosed a lumbar spine condition, a cervical spine condition, and a right shoulder condition and found that they did not impact his ability to work and perform occupational tasks. In a December 2016 DBQ and private medical opinion, the clinician opined that the Veteran could not sustain the stress from a competitive work environment or engage or adequately function in gainful work activity due to his PTSD symptoms. The clinician explained that the Veteran’s symptoms were more likely to occur in social or work settings causing him to have difficulty concentrating, be easily distracted, and less able to follow, remember, or listen to task instructions. The clinician further noted that the Veteran’s symptoms would result in increased fatigue, absences or tardiness, hypersensitivity to criticism, an inability to meet deadlines, difficulty conversing with others, and increased anger outbursts or conflicts with others. The clinician asserted that suicidal ideation would more likely than not become more prevalent in a work setting due to the Veteran’s repeated inability to perform tasks effectively, poor social skills, and feelings of worthlessness or hopelessness existing with depression. The clinician ultimately opined that the Veteran’s symptoms were severe enough to preclude him from sustaining substantial gainful employment activity. In a May 2017 private medical opinion, the clinician found that the Veteran would be unable to stand for 20 minutes without needing to lean on something, could only walk for 25 minutes slowly and unassisted, could sit for a total of 10 minutes at a time, and was unable to lift or carry more than 10 pounds. The clinician noted that he would need to leave early from or miss work for at least ten days per month, would require at least two additional breaks per day, and would be unable to stay focused for at least seven hours out of an eight-hour work day at least three times per month. The clinician ultimately opined that the Veteran was unable to maintain substantial gainful employment as a result of his service-connected disabilities. In a second May 2017 private medical opinion, the clinician found that the Veteran’s major areas of limitation were mental and physical activity involved in sustaining work. The clinician noted a documented history of mental health symptomatology, including being argumentative, fleeting thoughts of suicidal or homicidal ideations, intense emotion, impaired sleep, feeling worthlessness and broken down, struggles with concentration and memory, hallucinations, anger, and potential for aggression. The clinician opined that, as a result of the severity of his service-connected disability, the Veteran was totally and permanently precluded from performing work at a substantial gainful level. Based on the above, entitlement to TDIU is warranted. In this regard, the record reflects that the Veteran was unemployable and unable to secure a job or follow a substantially gainful occupation in June 2014. Furthermore, the record reflects that he met the schedular criteria for assignment of a TDIU in February 2015. While the SSA found that the Veteran’s inability to maintain employment was due, in part, to a psychiatric disability for which he is not service-connected, the December 2016 and May 2017 private medical opinions are strong evidence that the Veteran’s service-connected disabilities alone render him unemployable. As noted above, the private medical opinions found that the Veteran’s symptoms resulted in his inability to meet deadlines, converse with others, adequately concentrate, and remember work or work-related instructions. The opinions further found that the symptoms resulted in hypersensitivity to criticism, increased anger outbursts, and potential for aggression. Therefore, the appeal is granted. Finally, the Veteran has not raised any other outstanding issues, nor have any other issues been reasonably raised by the record for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Right Shoulder Strain: In a January 2017 private medical opinion, a private clinician described the Veteran’s right shoulder as significantly unstable posteriorly. The clinician said that he had weakness in the shoulder and pain in the scapula. The clinician diagnosed a posterior labral tear and opined that his right shoulder was progressively unstable and worsening with instability and difficulty performing functional activities of daily living. In light of the January 2017 private medical opinion indicating that the symptoms of his right shoulder condition have worsened, a remand is necessary to determine the current level of severity of all impairment resulting from his service-connected disability. Blurred Vision and Migraine Headaches: As an initial matter, blurred vision and headaches have been diagnosed in an August 2014 VA examination and a January 2017 medical treatment note, respectively. In a second January 2017 medical treatment note, a clinician diagnosed a mild TBI and found that the Veteran’s TBI symptoms included vision problems, including blurring and trouble seeing, and headaches. In light of the January 2017 medical treatment note delineating the Veteran’s TBI symptoms, an examination should be undertaken to determine the nature and etiology of any currently present blurred vision and migraine headaches, to include whether the Veteran’s blurred vision and migraine headaches were caused or aggravated by his service-connected TBI. Hearing Loss: A review of the record reveals that in an August 2016 medical treatment note, the Veteran reported having trouble hearing, explaining that his hearing was impacted by in-service exposure to UF radio waves while serving as a radio operator. In a subsequent January 2017 medical treatment note, the Veteran reported having severe hearing difficulty over the previous 30 days. In light of medical treatment notes indicating that he had trouble hearing that was caused or aggravated by his active service, an examination should be undertaken to determine the nature and etiology of any currently present hearing loss. Finally, current treatment records should be identified and obtained before a decision is made with regard to the current issues on appeal. The matters are REMANDED for the following actions: 1. Identify and obtain any pertinent, outstanding VA and private treatment records not already of record in the claims file. 2. Schedule the Veteran for an examination to determine the current status of all impairment resulting from his service-connected right shoulder strain. The claims file should be made available to and reviewed by the examiner. All indicated tests and studies should be performed. The examiner should provide all information required for rating purposes. 3. Schedule the Veteran for an examination to determine the nature and etiology of his blurred vision. The claims file must be made available to, and reviewed by the examiner. All indicated tests and studies should be performed. Based on the examinations results and review of the record, the examination should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that: a) the Veteran’s blurred vision is etiologically related to his active service; b) the Veteran’s blurred vision is caused or aggravated by a service-connected disability, to include his service-connected TBI; and c) the symptomatology of the Veteran’s blurred vision has been continuous since service. The rationale for all opinions must be provided. 4. Schedule the Veteran for an examination to determine the etiology of his migraine headaches. The claims file should be made available to, and reviewed by the examiner. All indicated studies should be performed. Based on the examination results and review of the record, the examination should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that: a) the Veteran’s migraine headaches are etiologically related to his active service; b) the Veteran’s migraine headaches are caused or aggravated by a service-connected disability, to include his service-connected TBI; and c) the symptomatology of the Veteran’s headache disability has been continuous since service. The rationale for all opinions must be provided. 5. Schedule the Veteran for an examination to determine the nature and etiology of any currently present hearing loss. The claims file must be made available to, and reviewed by the examiner. All indicated studies should be performed Based on the examination results and review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that: a) any currently present hearing loss is etiologically related to active service; b) any currently present hearing loss is caused or aggravated by a service-connected disability, to include his service-connected TBI; and c) the symptomatology of any currently present hearing loss has been continuous since service. The rational for all opinions must be provided. 6. Then, readjudicate the claims on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. L. HOWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Spigelman, Associate Counsel