Citation Nr: 18150928 Decision Date: 11/16/18 Archive Date: 11/15/18 DOCKET NO. 16-29 603 DATE: November 16, 2018 ORDER Entitlement to service connection for a left knee disability is denied. Entitlement to an increased rating higher than 60 percent for lumbosacral strain and thoracic DJD is denied. Entitlement to an increased rating higher than 30 percent for asthma is denied. Entitlement to an initial disability rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a total disability due to individual unemployability based on service-connected disabilities (TDIU) is granted, subject to controlling regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for a left foot disability, to include pes planus, is remanded. Entitlement to service connection for a right foot disability, to include pes planus is remanded. Entitlement to an initial compensable disability rating for right foot callus is remanded. Entitlement to an initial disability rating higher than 10 percent for right knee DJD is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has a left knee disability that is due to disease or injury in service. 2. The Veteran’s low back disability more nearly approximated incapacitating episodes of total duration of at least six weeks in the past 12 months, but did not include or involve unfavorable ankylosis of the entire spine. 3. The preponderance of the evidence shows that the Veteran’s forced expiratory volume (FEV-1) or FEV-1/forced vital capacity (FVC) measurements were not 55 percent or less of predicted value and the Veteran did not receive at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three times per year) courses of systemic (oral or parenteral) corticosteroids. 4. The symptoms and overall impairment caused by the Veteran’s psychiatric disability more nearly approximated occupational and social impairment with deficiency in most areas, but did not more nearly approximate total occupational and social impairment. 5. The evidence reflects that the Veteran’s service-connected disabilities are of such nature and severity as to prevent him from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for an increased rating higher than 60 percent for a low back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code (DC) 5243. 3. The criteria for an initial disability rating higher than 30 percent for the Veteran’s asthma have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.97, DC 6602. 4. With reasonable doubt resolved in favor of the Veteran, the criteria for an increased rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.130, DC 9411. 5. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1986 to December 1992, and from August 2006 to May 2007. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran properly appealed his claims for increased ratings. In a January 2016 rating decision, the RO awarded an increased initial rating of 50 percent for PTSD effective July December 17, 2009, the date of claim for service connection; and an increased rating of 60 percent for a low back disability effective December 19, 2011, the date of the claim for increased rating. The Veteran did not indicate satisfaction with the grant of these ratings, and these issues therefore remain on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993) (a veteran is presumed to be seeking the maximum possible rating unless he indicates otherwise). In August 2016, the Veteran submitted additional medical evidence along with a waiver of RO consideration. Therefore, a remand for the RO to review the evidence in the first instance is not necessary. 1. Entitlement to service connection for a left knee disability Service connection will be granted if the evidence demonstrates that current disability resulted from a disease or injury incurred in active military service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service incurrence of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The requirement that a current disability exist is satisfied if the claimant had a disability at the time his claim for VA disability compensation was filed or during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). See also Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (Board erred in failing to address pre-claim evidence in assessing whether a current disability existed, for purposes of service connection, at the time the claim was filed or during its pendency). Lay persons may provide evidence of diagnosis and nexus under 38 U.S.C. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In relevant part, 38 U.S.C. § 1154(a) (2012) requires that VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). “[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); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (“[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence”). The Veteran contends that he has a left knee disability that is related to or incurred in service. Service treatment records (STRs) in December 2006 document that the Veteran experienced knee pain that could be related to foot problems. However, STRs are otherwise silent as to any complaints, treatments, or diagnoses for a left knee disability or symptoms of the left knee. Likewise, post-service treatment records are silent as to any complaints, treatments, or diagnoses for a left knee disability or symptoms of the left knee. An April 2013 VA examination report reflects knee pain that started in 2006, but the Veteran stated that his left knee was currently asymptomatic. Range of motion of the left knee was flexion to 140 degrees and extension to 0 degrees. The examiner opined that there were no objective findings on the left knee as it was completely asymptomatic. In Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018), the Federal Circuit held that a diagnosis is not required to meet the current disability requirement. For example, pain alone can constitute disability even if not connected to a current underlying condition, if it causes impairment in earning capacity. Id. Even considering this broad definition of disability, however, the Veteran has not met the current disability requirement for the following reasons. While the April 2013 VA examiner noted in-service knee pain, he also noted the Veteran’s remark that his left knee was currently asymptomatic. In addition, the physical examination of the left knee was normal, and the VA examiner and post-service records reflect no treatments or diagnosis of a left knee disability. There is no lay or medical evidence of current impairment of the left knee or impairment that is due to disease or injury in service. For the foregoing reasons, the preponderance of the evidence reflects that the Veteran does not have a left knee disability or one that is due to disease or injury in service. The benefit of the doubt doctrine is therefore not for application and entitlement to service connection for this claimed disability is thus not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102 Increased Rating Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Likewise, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods. If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath, 1 Vet. App. at 589. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 2. Entitlement to an increased rating higher than 60 percent for lumbosacral strain and thoracic DJD The Veteran contends that his service-connected low back disability symptoms warrant a rating higher than 60 percent, effective December 19, 2011. The Veteran filed his claim for an increased rating on December 19, 2011. When evaluating musculoskeletal disabilities, VA must consider granting a higher rating in cases in which the Veteran experiences functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Under the General Rating Formula for Diseases and Injuries of the Spine, a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine, forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a. Following the criteria set forth in the General Rating Formula for Diseases and Injuries of the Spine, in relevant parts, Note (1) instructs to evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Under current provisions for rating intervertebral disc syndrome (IVDS), IVDS (preoperatively or postoperatively) is evaluated either under the General Rating Formula for Diseases and Injuries of the Spine as noted above, or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. 38 C.F.R. § 4.71a, DC 5243. For evaluation of IVDS, with incapacitating episodes having a total duration of at least six weeks during the past 12 months, a 60 percent rating is assignable. Id. For purposes of evaluations under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. A September 2012 VA examination report reflects that the Veteran had chronic low back pain. He reported that any movement exacerbated his back pain, but he denied bladder or bowel incontinence, or radiculopathy. He stated he could lift weights up to 25 pounds and walk half a mile. He remarked that he had to be mobile and not sedentary or his back stiffened up. Range of motion was flexion to 90 degrees, extension to 30 degrees, bilateral lateral flexion to 30 degrees, and bilateral lateral rotation to 30 degrees. There was no pain on movement and no additional limitation of motion with repetition. The examiner also noted that there was no functional loss, tenderness, or guarding. There was normal strength testing, deep tendon reflex, and sensory examination; and there was no radicular pain or symptoms. The Veteran did not have IVDS or use assistive devices. An August 2015 VA examination report documents worsening back pain. The Veteran described his flare-ups as very intense and that functional loss resulted in less range of motion. Range of motion was flexion to 60 degrees, extension to 20 degrees, bilateral lateral flexion to 20 degrees, and bilateral lateral rotation to 5 degrees, with pain on all movement that causes functional loss. There was normal strength testing, hypoactive deep tendon reflexes in the bilateral ankles, and normal sensory examination. There was positive straight leg raise of the right lower extremity; and moderate intermittent pain, paresthesias, and numbness in the right lower extremity. The examiner found that there was involvement of right sciatic nerve and moderate radiculopathy of the right lower extremity. The Veteran had IVDS with episodes lasting a total duration of at least 6 weeks in the past 12 months, and he used a brace occasionally. Upon review of the evidence, the Board finds that an increased rating higher than 60 percent for a low back disability is not warranted. The evidence does not reflect that the Veteran had unfavorable ankylosis of the entire spine, which would warrant a rating higher than 60 percent. To the contrary, the record shows that, at worse, the Veteran had decreased range of motion of flexion to 60 degrees in August 2015. While the Veteran also endorsed flare-ups, there is no evidence either medical or from lay statements, that indicates the Veteran had unfavorable ankylosis of his entire spine. While VA must in some circumstances consider functional impairment in addition to limitation of motion due to factors such as pain, weakness, premature or excess fatigability, and incoordination, this rule does not apply where, as here, the Veteran is receiving the maximum schedular evaluation based on limitation of motion and a higher rating requires ankylosis. See Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997). Consideration has been given to an increased evaluation for the Veteran’s lumbar spine disability under other potentially applicable diagnostic codes. See Schafrath, 1 Vet. App. at 595. As noted, the August 2015 VA examiner remarked that the Veteran had IVDS with incapacitating episodes totaling at least six weeks out of the past 12 months. As such, the RO awarded a rating of 60 percent under the rating criteria from the date of the claim for increase. The Board further finds that no additional separate ratings are warranted for neurological disorders. In that connection, the Board notes that service connection for bilateral radiculopathy of the lower extremity is addressed in the remand portion below. Further, the Veteran denied any bladder or bowel incontinence. Thus, the Board finds that no other separate rating for neurological disabilities is warranted. The Board has considered the Veteran’s claims for increased ratings for a low back disability and decided entitlement based on the evidence. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claim. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). 3. Entitlement to an increased rating higher than 30 percent for asthma The Veteran is currently service-connected for asthma, rated as 30 percent disabling under 38 C.F.R. § 4.97, DC 6602. He filed his claim for increased rating in December 2011. Under DC 6602, a 30 percent evaluation is warranted for bronchial asthma for the following: FEV-1 of 56 to 70 percent predicted, or; FEV-1/ FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication. A 60 percent evaluation requires FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 100 percent rating is assigned for FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. A September 2012 VA examination report reflects worsening shortness of breath. The Veteran reported that he was using his inhaler more often, and took two puffs three to four times daily when before he used it two times per day. He also stated that he was hospitalized for his asthma one year ago, but he had never been intubated. The examiner noted that exacerbations were less frequently than monthly. A 2010 post-bronchodilator pulmonary function test (PFT) results revealed FVC of 78.2 percent; FEV-1 of 73.7 percent; and FEV-1/FVC of 76 percent. The examiner noted that the percentage of the FEV-1 results most accurately reflected the Veteran’s level of disability. An August 2015 VA examination report documents that the Veteran’s asthma was about the same since his last VA examination. He had not had to go to a hospital for any asthma attack in last 12 months, and he used inhalational bronchodilator therapy daily. A 2010 post-bronchodilator PFT results revealed FVC of 78.2 percent; FEV-1 of 73.7 percent; and FEV-1/FVC of 76 percent. The examiner noted that the percentage of the FEV-1 results most accurately reflected the Veteran’s level of disability. The Veteran reported that he had shortness of breath if he performed strenuous work. The evidence of record does not show that the Veteran’s FEV-1 or FEV-1/FVC was less than 56 percent at any time during the appeal period. The September and August 2015 VA examinations reveal that the Veteran’s FEV-1 result of 73.1 percent most accurately reflected the Veteran’s level of disability. Further, VA treatment records did not indicate that the Veteran had at least monthly visits to a physician for required care of exacerbations, intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids, or more than one attack per week with episodes of respiratory failure. Accordingly, the Veteran’s service-connected asthma more closely approximates a 30 percent disability rating. While veterans are competent to opine on some medical matters, the degree of disability of the Veteran’s asthma is a complex, non-observable process that is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-09 (lay person competent to identify varicose veins); Falzone, 8 Vet. App. at 403 (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). While the Veteran may feel that his asthma is worse than reflected by the schedular rating, he could not be expected to accurately predict the percentage of his PFT, or properly prescribe his inhalation medication. His statements on this question are therefore not competent. The above determinations are based on consideration of the applicable provisions of VA’s rating schedule. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with respect to this claim. See Doucette, 28 Vet. App. at 369-70. 4. Entitlement to an initial disability rating of 70 percent, but no higher, for PTSD. The Veteran contends that his service-connected PTSD warrants an initial disability rating higher than 50 percent under 38 C.F.R. § 4.130, DC 9411. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will also consider the extent of social impairment, but shall not assign a rating solely based on social impairment. 38 C.F.R. § 4.126(b). Under the General Rating Formula, a 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances ( including work or a work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the veteran’s symptoms, but it must also make findings as to how those symptoms impact the veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Post-service VA treatment records in September 2009 document that the Veteran was depressed for several years. He stated that if he did not drink or take over the counter (OTC) sleeping medication he could not sleep. With medication or alcohol, he slept about four to five hours per night. He had nightmares of his time in Desert Storm, and was currently separated from his second wife. He felt that the separation was his fault because he was irritable, easily angered, and the police were called to their house for domestic violence, although he denied that he ever hit his wife despite contrary police reports. He had three children that he did not see, and was currently staying with friends. He isolated himself to avoid losing his temper with people, and left the house twice a week for the Vocational Rehabilitation program, which he credited for getting him out of the house and seeing other people. He was well-groomed, had normal speech, his mood was depressed, his affect mildly constricted, his though process was linear, and his though content appropriate. He was oriented to person, time, and situation; his short and long-term memory were intact; his concentration was good; and his impulse control was good. He also had good insight and judgment, adequate appetite, limited interests, irritability and anger, nightmares, and anxiety. VA treatment records in November 2011 reflect normal appearance and speech. The Veteran stated that he slept about seven hours per night with medication. His appetite came and went, his mood was depressed, and his affect anxious. His goal was to finish school, where he studied medical terminology. He denied suicidal and homicidal ideation, and stated that he preferred to be alone with his family. He felt guilty, and he dreamt he was left behind and did not finish his mission. He liked to play with his son, and reported social support from friends and family. He attended church a few times per month, and he helped his wife with shopping and chores. He currently lived with his wife and three children, and was married for 11 years. A September 2012 VA examination report reflects that the Veteran enjoyed being with his family, and he and his extended family socialized frequently. He went to restaurants and did not report any difficulty with this activity. He performed his activities of daily living routinely and independently, and performed household chores and parental duties. He attempted to perform projects around the house such as painting and fixing appliances, but his wife did not want him to do those; he did not report the reason why. He was not working, and stated that he could not find a job because of his orthopedic problems and asthma. Psychiatric symptoms included depressed mood, anxiety, chronic sleep impairment, disturbance of motivation and mood, hypervigilance, exaggerated startle response, marked diminished interest or participation in significant activities, and feeling of detachment or estrangement from others. A June 2015 Disability Benefits Questionnaire (DBQ) completed by a private psychologist documents that the Veteran had been married to his second wife for 15 years, and he had three adult children and two school-age children. He lived with his wife and three children. The examiner noted that he kept his struggles to himself because he did not want to burden others. He was socially isolated and withdrawn. He attended college but did not earn a degree because he felt he did not fit in, and he was not able to concentrate or focus. Psychiatric symptoms included difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, exaggerated startle responses, depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, near-continuous panic or depression affecting the ability to function independently, chronic sleep impairment, flattened effect, disturbance of motivation and mood, difficulty adapting to stressful circumstances including worklike setting, and inability to establish effective relationships. The Veteran stated that he no longer enjoyed the simplest activities, and complained of increased trouble with short and long-term memory. The examiner noted that the Veteran’s attention and concentration appeared variable, and he struggled to remember basic information. His speech flow was normal, although he was brief with the information offered; his thought content was appropriate and goal-oriented; he denied hallucinations; and his mood was anxious and nervous with restricted affect. The examiner noted that the severity of the Veteran’s PTSD had been constant since the award of service connection in 2009, and she opined that the Veteran had occupational and social impairments with deficiencies in most area. An August 2015 VA examination report indicates that the Veteran was married for 15 years, and lived with his wife and three children. The Veteran reported that his marriage and home life were “fine and beautiful.” The Veteran stated that he spent most of his time at home, reading and watching television. He enjoyed spending time with his youngest child, and reported that he had one friend that he visited once a month. However, most of his socialization was with his family. The Veteran explained that he tried to go to college in the past, but was unable to earn a degree because he missed class for appointments and other obligations. He had been unable to find employment, and had not worked since the military. The Veteran did not undergo mental health treatment, and received psychotropic medications from his primary care physician. Psychiatric symptoms included markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, irritable behavior and angry outbursts, hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance, depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances including work or a worklike setting. As previously noted, the Veteran has a 50 percent initial disability rating. For the following reasons, a disability rating of 70 percent, but no higher, for PTSD is warranted for the entirety of the appeal. The evidence shows that the Veteran was hypervigilant, depressed, and anxious. He experienced chronic sleep impairment, irritability and anger outbursts, and isolationism. He stated that he was socially withdrawn and mostly kept to himself because he was afraid of hurting others. He had chronic sleep impairment and nightmares, and reported that he could only fall sleep with medication or drinking. In addition, he experienced panic attacks that occurred weekly or less often, and continuous panic or depression affecting the ability to function independently. He had a good relationship with his family, and while he had one friend, he only visited him about once a month. Further, the evidence reflects difficulty with concentration and focus, as well as worsening short and long-term memory. The Veteran also experienced exaggerated startle responses, estrangement from others, and markedly diminished interest in activities. He also had difficulty adapting to stressful circumstances, suspiciousness, and disturbances of mood. Thus, the evidence reflects that, for the entirety of the appeal period, the Veteran exhibited symptoms of such type, severity, and frequency as to more closely approximate a disability rating of 70 percent for his service-connected PTSD. However, neither the symptoms nor overall impairment more nearly approximate total occupational and social impairment required for a 100 percent rating. The evidence shows that the Veteran has difficulty in establishing and maintaining social relationships, as evidenced by his lack of friendships. Nevertheless, the Veteran reported that he had a good relationship with his family and enjoyed socializing with them and playing with his youngest son. In addition, while the Veteran experiences anger outbursts and irritability, he was not in persistent danger of hurting himself or others. He was also oriented to time, place, and person; he maintained good personal hygiene; there was no evidence of gross impairment in thought processes, communication or their equivalents; his speech was normal, clear, and goal-oriented; and his insight and judgment fair. Thus, an initial rating higher than 70 percent for his service-connected PTSD is not warranted because neither the symptoms nor overall impairment more nearly approximated the total occupational and social impairment required for a 70 percent rating. The above determinations are based on consideration of the applicable provisions of VA’s rating schedule. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with respect to this claim. See Doucette, 28 Vet. App. at 369-70. 5. Entitlement to a TDIU The Veteran contends that he is unable to secure substantially gainful employment due to his service-connected disabilities. VA will grant a TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from securing and following “substantially gainful employment” consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 24.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). 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). The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system, such as the orthopedics, will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a). The Board must evaluate whether there are circumstances in the Veteran’s case, apart from any nonservice-connected disability and advancing age, which would justify a TDIU due solely to the service-connected disabilities. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). The Veteran’s service connected disabilities, to include the decision herein, are: PTSD, rated 70 percent from December 17, 2009; lumbar spine disability, rated 20 percent from May 29, 2007, and 60 percent from December 19, 2011; asthma, rated as 30 percent from November 6, 2007; right knee disability, rated as 10 percent from November 28, 2011; left thumb disability, rated as noncompensable from May 29, 2007; left wrist disability, rated noncompensable from April 26, 2010; and right foot callus, rated noncompensable from January 19, 2012. The Veteran has a combined rating of 20 percent from May 29, 2007, 80 percent from December 17, 2009; and 90 percent from November 28, 2011. Hence, the Veteran meets the percentage criteria for a TDIU laid out in 38 C.F.R. § 4.16(a) from December 17, 2009, when he had one single disability rated at 60 percent or more, and a single disability rated as 40 percent and a total evaluation of at least 70 percent. Even so, to grant TDIU it must be found that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. Consequently, the Board must determine whether the Veteran’s service-connected disabilities combine to preclude him from engaging in substantially gainful employment (work that is more than marginal, which permits the individual to earn a “living wage”). Moore v. Derwinski, 1 Vet. App. 356 (1991). The fact that a Veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the Veteran, because of service-connected disabilities, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Inability to work due to advancing age may not be considered. 38 C.F.R. §§ 3.341(a), 4.19 (2016). In making its determination, VA considers such factors as the extent of the service-connected disabilities, and employment and educational background. See 38 C.F.R. §§ 3.340, 3.341, 4.16(b), 4.19. The evidence of record reveals that the Veteran has a high school diploma and he some college education. He was a truck driver from August 2006 to May 2007, but did not work since he left military service in May 2007. A June 2015 letter from a private psychologist addresses the Veteran’s ability to work based on his service-connected mental health impairment. The psychologist found that the Veteran would miss or have to leave early from work three or more days per month, that he would have difficulty concentrating more than three days per month, and that he would not be able to stay focused for at least seven hours of an eight-hour workday. She opined that if he were subjected to the normal pressures and constructive criticisms of employment, he would respond inappropriately more than once per month in an angry manner but would not actually become violent. She believed that the Veteran’s PTSD and social impairment were emotionally debilitating, and that based on upon a mental status evaluation and clinical interview, the Veteran had occupational and social impairments. She stated that the Veteran could not sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his PTSD. The Veteran described not getting enough restful sleep and feeling fatigued nearly every day, which would be a safety issue in the workplace. He reported difficulty remembering events, requests, and occasionally forgetting details or sequencing that would affect his employment. He had difficulty maintaining and sustaining a steady mood, and this inconsistent mood lead to problems in his social and work life. He also reported feeling nervous and worried, and struggled with ongoing anxiety. Although he was unclear about his anxiety triggers, he did not leave the house as much as he would like, and the examiner noted that this type of anxiety was a safety hazard in a job. In July 2016, the Veteran submitted an opinion from a vocational expert, who reviewed his entire claims file. She found that the Veteran was an individual of younger age that served in the military for approximately seven years and worked as a truck driver after service, but had not worked since 2007 reportedly due to his physical and mental impairments. She noted that the Veteran had a combination of physical and emotional conditions, which interacted in terms of severity level, and that the major area of limitations appeared to be mental and physical activity involved in sustaining work. Based on a review of the claims file, she opined that the Veteran was totally and permanently precluded from performing work at a substantially gainful level due to the severity of his service-connected low back disability, PTSD, asthma, right knee DJD, left thumb disability, and right foot callus. The above evidence shows that the Veteran’s service-connected disabilities have precluded him from obtaining and retaining substantially gainful employment. Moreover, the “applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner.” Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Entitlement to a TDIU is therefore warranted. REASONS FOR REMAND 1. Entitlement to service connection for bilateral foot disability, to include pes planus, is remanded. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty. See 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. Every Veteran is presumed to have been in sound condition at entry into service except as to defects, infirmities, or disorders noted at the time of such entry. 38 U.S.C. § 1111. Here, a June 2005 report of medical examination for enlistment into the Army reserves reflects moderate asymptomatic pes planus, a December 2006 report of medical examination indicates symptomatic moderate pes planus, and a December 2006 STR assessed congenital pes planus. These notations reflect that the presumption of soundness is not for application with regard to bilateral pes planus. It is for application with regard to other foot disorder not noted on the entrance examination. The question thus becomes whether the pes planus was aggravated by service. The Veteran contends that he currently has a bilateral foot disorder due to service. Specifically, he claims that he has pain in his arch that started while in service and worsened over time. A March 2007 report of medical examination for a medical board reflects moderate symptomatic pes planus. An April 2013 VA examination report reflects diagnoses of right foot pes planus, and bilateral arthritis in the feet. The examiner only addressed the Veteran’s right foot pes planus, and opined that right foot pes planus was not related to any injury as it was a congenital condition. In addition, the examiner also found that it was not related to his receipt of the Parachutist Badge because it was a congenital disease, and that it was not aggravated beyond the natural progression by active service since the present examination showed the condition to be almost asymptomatic without any sign of progression or aggravation. Further, there was no evidence of pes planus on the left foot. The Board finds the April 2013 VA opinion to be inadequate because the examiners failed to provide a rationale for his conclusion, and he did not address the nature and etiology of the Veteran’s diagnosed arthritis of the bilateral feet. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). A remand is therefore warranted for a new VA opinion. 2. Entitlement to an initial compensable disability rating for right foot callus is remanded. The Veteran contends that his right foot callus, currently rated as noncompensable under 38 C.F.R. § 4.118, DC 7819, warranted a higher rating. An April 2013 VA examination report reflects that the Veteran had a right foot callus close to the heel area that measures 3 centimeters (cm) by 3 cm. The VA examiner did address whether the callus is painful or unstable. As such, the Board finds that a VA scar examination is necessary to determine the severity of the Veteran’s right foot callus. See Barr v. Nicholson, 21 Vet. App. 30 (2007) (holding that once VA undertakes the effort to provide an examination or obtain medical opinion, it must ensure that one is provided or obtained that is adequate for the determination being made). 3. Entitlement to an initial disability rating higher than 10 percent for right knee DJD is remanded. The Veteran’s right knee disability is currently rated as 10 percent disabling. The Board notes that the Veteran was provided a VA examination for his right knee in April 2013. The Veteran reported that his right knee had worsened and gave out. Range of motion was flexion of 110 degrees and extension of 0 degrees. There was no additional limitation of motion after repetition, and no additional limitation of functional ability of the knee joint during flare-ups or repeated use over time. The Board finds the VA examination and private DBQ to be inadequate because they did not include range of motion findings for passive range of motion, nor specified whether the results were weight-bearing or nonweight-bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016). Further, the VA examiner “failed to ascertain adequate information—i.e., frequency, duration, characteristics, severity, or functional loss—regarding his flares by alternative means” and then “estimate the Veteran’s functional loss due to flares based on all the evidence of record—including the Veteran’s lay information.” Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). As noted by the Court in Sharp, such findings are contemplated by the VA Clinician’s Guide. As such, a new VA examination is necessary to properly assess the severity of the Veteran’s right knee disability as pertaining to the Veteran’s functional limitations and additional limitation of motion due to flare-ups. The matters are REMANDED for the following action: 1. Refer the Veteran’s claims file to an appropriate physician to address the nature and etiology of the Veteran’s bilateral foot disability. The entire claims file, and a copy of this remand, must be provided to and reviewed by the examiner. After reviewing the record, the VA examiner should address the following: (a.) Whether the Veteran’s bilateral arthritis of the foot is at least as likely as not (50 percent probability or more) related to or caused by service, to include parachute jumps. (b.) Whether bilateral pes planus increased in severity during service. If so, was there clear and unmistakable evidence that the increase due to the natural progress of the disease. The examiner must provide a detailed rationale for any opinion expressed, citing to the relevant facts in the claims file as well as any relevant medical literature 2. Schedule the Veteran for a VA examination to determine the current severity of his right foot callus, currently rated as a scar. The Veteran’s VA claims file and a copy of this Remand should be made available to, and should be reviewed by the examiner. All indicated tests and studies should be performed and findings reported in detail. The examination should be conducted in accordance with the current disability benefits questionnaire. 3. Schedule the Veteran for a VA examination to determine the current severity of his right knee disability. The Veteran’s VA claims file and a copy of this Remand should be made available to, and should be reviewed by the examiner. All indicated tests and studies should be performed and findings reported in detail. The examiner should conduct the examination in accordance with the current disability benefits questionnaire, to include range of motion testing (expressed in degrees) in active motion, passive motion, weight-bearing, and nonweight-bearing consistent with 38 C.F.R. § 4.59 as interpreted in Correia, as well as the degree at which pain begins. In addition, the examiner must address any additional functional impairment or limitation of motion due to flare-ups, even if the Veteran is not currently experiencing a flare-up. The examiner must ascertain adequate information—i.e., frequency, duration, characteristics, severity, or functional loss—regarding his flares by alternative means, such as the medical treatment records and the Veteran’s lay statements. Such findings are consistent with the VA Clinician’s Guide. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Leifert, Associate Counsel