Citation Nr: 18150964 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 14-37 733 DATE: November 16, 2018 ORDER Entitlement to service connection for a kidney disability is denied. Entitlement to an effective date earlier than August 12, 2015, for a 100 percent evaluation for posttraumatic stress disorder (PTSD) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) for the period from August 12, 2014, to August 12, 2015, and no earlier, is granted. REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a left ankle disability is remanded. FINDINGS OF FACT 1. The Veteran does not have a current kidney disability. 2. For the period from August 12, 2014, to August 12, 2015, it is not factually ascertainable that the Veteran’s PTSD had increased in severity at any point such that it was manifested by 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, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. 3. Beginning August 12, 2014, the Veteran’s service-connected disabilities prevented him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a kidney disability are not met. 38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for entitlement to an effective date earlier than August 12, 2015, for a 100 percent evaluation for PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC or Code) 9411. 3. The criteria for entitlement to a total disability rating based on individual unemployability for the period from August 12, 2014, to August 12, 2015 have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.2, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty in the United States Army from January 1968 to January 1970. This matter comes before the Board of Veterans’ Appeals (Board) from rating decisions issued by a Regional Office (RO) of the Department of Veterans Affairs (VA) in December 2013 and April 2017. 1. Entitlement to service connection for a kidney disability Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau, supra. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. An appellant need only demonstrate that there is an “approximate balance of positive and negative evidence” in order to prevail. See Gilbert, 1 Vet. App. at 53. At the May 2018 Board hearing, the Veteran testified that while serving on active duty in Vietnam he had not been deployed very long when he began to develop high fevers and would begin to shake and tremble in the middle of the night. He indicated that at one point his fever had gotten so bad during a convoy run that he had to lie down underneath his truck to wait for it to pass and eventually was treated at a hospital with a temperature of 105 degrees. He contended that he had significant blood in his urine that he stated had been seeping out of one of his kidney. The Veteran stated further that he was treated with medication for those symptoms for roughly one year. The Board finds no reason to doubt the credibility of the Veteran’s statements regarding his in-service fevers and bloody urine and notes that he is competent to report those observable symptoms. However, the record does not contain any significant arguments or contentions that that episode of fever and potential kidney-related disease has caused any problems or functional deficits since the Veteran filed his claim for service connection for a kidney condition in June 2012. Notably, the Veteran also acknowledged at the hearing that he had recently been evaluated at a VA clinic and was found to have normal kidney functioning. He ultimately agreed that at the time of the hearing, he did not have a diagnosis regarding his kidneys. Although the Board is sympathetic to the Veteran’s contentions, the cornerstone of any service connection claim is the existence of a current disability. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). “In the absence of proof of a present disability, there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Moreover, the requirement of a current disability is “satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim.” See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Given the lack of any competent contention that the Veteran has had a kidney-related disability at any point since he filed his claim for benefits, the Board has reviewed the Veteran’s treatment records and examination reports to determine whether such a disability has been present since June 2012. However, as the Veteran suggested at the hearing, the competent medical evidence fails to indicate he has had a kidney-related diagnosis at any point since his claim. On the contrary, at a VA clinical evaluation in March 2014, both a urinalysis test and a renal function test were reportedly normal. As the Board does not find that there is competent, probative, and credible evidence that would suggest the Veteran has had any kidney-related disease or condition since he filed his claim for benefits, the Board cannot find that the criteria for service connection for such a disability have been met and the Veteran’s claim must be denied. As there is no competent evidence of record to substantiate the claim, the Board also finds that the doctrine of the benefit of the doubt is not for application. 2. Entitlement to an effective date earlier than August 12, 2015, for a 100 percent evaluation for PTSD The Veteran seeks an earlier effective date for the April 2017 award of a 100 percent evaluation for PTSD. In his June 2017 notice of disagreement he explained that he had been complaining of PTSD-related symptoms to the same degree that he had during the earlier appeal that led to his ultimate March 2015 grant of service connection for PTSD. He reiterated in the January 2018 VA Form 9 that his PTSD symptoms had not changed since he first started his claim for service connection in 2012 and argued that the 100 percent evaluation should go back to the date of that initial claim. He again reiterated those sentiments at the May 2018 Board hearing. Accordingly, the Veteran’s claims could be characterized in several different ways. First, to the extent his current contentions represent a disagreement with the initial 70 percent evaluation assigned in the March 2015 rating decision that granted service connection for PTSD, the Board finds that the Veteran’s claim must fail. In general, previous determinations, which are final and binding, including decisions of service connection, degree of disability and other issues, will be accepted as correct in the absence of clear and unmistakable error (CUE). 38 U.S.C. § 5109A; 38 C.F.R. § 3.105(a). To establish a valid CUE claim, an appellant must show that either the correct facts, as they were known at the time, were not before the adjudicator, or that the statutory or regulatory provisions extant at the time were incorrectly applied. Russell v. Principi, 3 Vet. App. 310 (1992). Here, the Veteran had one year to file a notice of disagreement after receiving the March 2015 notice of the grant of service connection and assignment of a 70 percent evaluation for his PTSD. 30 C.F.R. § 20.302(a). Although the Veteran stated at the hearing that he had appealed that initial decision, the record does not indicate that the Veteran gave VA any indication that he disagreed with the 70 percent evaluation assigned within a year of being notified of the decision. As such, the Board finds that it is final. The record also fails to include any evidence that the Veteran has contended with any specificity that the March 2015 rating decision assigning that 70 percent evaluation included CUE with respect to that issue. Accordingly, to the extent that the Veteran’s current contentions represent a disagreement with the March 2015 rating decision, the Board finds that such a disagreement is untimely and, given the absence of any allegations of CUE, the Veteran’s claim must be denied. While the record does not show that the Veteran filed a timely notice of disagreement with the earlier March 2015 rating decision, he did submit such a timely notice with respect to the April 2017 grant of a 100 percent evaluation, which was assigned to the Veteran’s PTSD effective August 12, 2015. He also submitted a timely substantive appeal after receiving a December 2017 Statement of the Case. Therefore, the issue of the effective date of the 100 percent evaluation is properly before the Board. The general rule for the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. However, for claims for increases in the evaluation of a service-connected disability, the effective date may be assigned on the “[e]arliest date as of which it is factually ascertainable based on all evidence of record that an increase in disability had occurred if a complete claim or intent to file a claim is received within 1 year from such date.” 38 C.F.R. § 3.400(o)(2). The claim for an earlier effective date currently before the Board arises from a claim for a TDIU that was submitted in August 12, 2015. As the Veteran contended in that form that his prostate cancer and PTSD prevented him from being able to work, VA construed that claim as both a claim for entitlement to a TDIU and a claim for an increased evaluation for his recently service-connected PTSD. As such, pursuant to 38 C.F.R. § 3.400, the only authority the Board has to grant his claim for an effective date earlier than August 12, 2015, is if the Board finds that it is factually ascertainable that an increase in severity of the Veteran’s PTSD had occurred within a year of the Veteran’s August 2015 claim at some point such that the criteria for a 100 percent evaluation were met. After reviewing the pertinent evidence of record relating to the Veteran’s psychological functioning in the year prior to his August 2015 claim, the Board does not find that such a factually ascertainable increase had occurred in that period. The Veteran’s disability has been evaluated at all points during the current appeal period pursuant to Diagnostic Code 9411, which is assigned to the evaluation of PTSD, and has been rated pursuant to the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under the General Rating Formula, a 70 percent evaluation is warranted where the disorder is manifested by 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 that is 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 an inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. A veteran “may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Symptoms listed in the General Rating Formula serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. They are not intended to constitute an exhaustive list. Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). Initially, the Veteran’s own contentions with respect to the severity of his PTSD would appear to weigh against a finding that his PTSD had increased to a severity consistent with a 100 percent evaluation on any particular date within the year leading up to his August 2015 claim for a TDIU. On the contrary, as explained above, in both his notice of disagreement and substantive appeal, the Veteran argued that he had experienced the same level of PTSD-related symptoms that he contended warranted a total disability rating ever since he initially filed his claim for service connection for that disability in 2012. At the hearing, the Veteran explained that he had held back certain symptoms at the time he was awarded a 70 percent evaluation and should not have. His wife further stated that the Veteran had been displaying the same symptoms in 2012 as he experienced at the time of the Board hearing. She explained that he did not want to be around people and on bad days she would have to take him out to a field where there were no other people. The Veteran’s spouse also noted that there had been a two-year period during which the Veteran would not even want to go to church or see his family. The Board sympathizes with the symptoms reported by the Veteran and his spouse and does not doubt the sincerity of their Board testimony. However, the Board is bound by the statutes and the regulations governing the effective date of VA disability compensation benefits. The statements of both the Veteran and his spouse do not represent probative, competent, and credible statements establishing that the Veteran’s PTSD had increased in severity at a specific point in the year leading up to his August 2015 claim. Such a showing is necessary to succeed on his claim for an earlier effective date under 38 C.F.R. § 3.400(o)(2). A review of the Veteran’s clinical treatment records also fails to uncover evidence that there had been a factually ascertainable increase in severity in the year leading up to August 12, 2015, such that the criteria for a 100 percent evaluation under the General Ratings Formula had been met. For instance, at a VA clinical evaluation in September 2014, the Veteran reported that he continued to have a depressed mood at baseline, including a lack of energy and motivation, irritability, and isolation, but he stated that he had been sleeping better. The Veteran also reportedly denied suicidal ideation but did acknowledge “being fine with” not waking up some day and endorsed daily intrusions of thoughts of Vietnam in addition to increased stress and anxiety levels when leaving the house. Notwithstanding those significant symptoms, the Veteran underwent what appears to be a largely normal mental status examination at that time. He was noted to have organized and goal-directed thought content, coherent and unimpaired speech, an appropriate and unremarkable affect, and demonstrated no evidence of excessive agitation or restlessness. Although the Veteran did have a mildly dysphoric mood, the treating clinician reported no signs of psychotic symptoms. These signs and symptoms do not approximate the level of severity contemplated by a 100 percent such as gross impairment in thought processes or communication, memory loss, disorientation, or inability to perform activities of daily living. Overall, the subsequent clinical evidence relating to the period leading up to the Veteran’s August 12, 2015, claim for benefits follows a similar pattern. In making this determination, the Board has considered a private mental health evaluation report from October 2014. At that time, the Veteran was noted to have symptoms of constant night sweats, nightmares and sleep disturbances leading to an average of only three hours of sleep per night, difficulty with several holidays, and hypervigilance and paranoia in large crowds. That clinician also reported that the Veteran had difficulty concentrating and on occasion became very angry and had outbursts. He ultimately assigned the Veteran a global assessment of functioning (GAF) score of 45 and recommended a 100 percent evaluation. A GAF score of 41-50 contemplates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See DSM-IV at 44-47. The clinician who provided this report appears to possess the medical knowledge, training, and experience to provide a competent opinion regarding the medically complex question of the specific clinical signs and findings that have been caused by the Veteran’s PTSD and the impact this disability has on the Veteran’s ability to function occupationally and socially. However, it must be considered in the context of all of the probative, credible, and competent evidence of record, including the treatment note described above from only a month earlier at which the Veteran’s treating clinician reported generally milder psychiatric signs and symptoms. As the October 2014 report appears to be inconsistent with the overall clinical picture described in numerous VA treatment notes regarding the Veteran’s PTSD from the year leading up to August 2012, the Board finds that it is of little probative weight and does not represent substantially probative evidence that Veteran’s PTSD had increased at a factually ascertainable date in that period such that the criteria for a 100 percent valuation were met. Underscoring this finding and assignment of weight is a statement from the Veteran from only a day after that private October 2015 report in which he described less than total social impairment. Specifically, although the Veteran clearly was experiencing PTSD symptoms documented by his treatment notes, he indicated he continued to have warm, close relationship with his siblings. Similarly, a statement from the Veteran’s spouse submitted in October 2014 lends further weight to the finding that his PTSD-related symptoms had undergone a gradual severity that significantly predated the August 2015 claim for benefits. In that statement, the Veteran’s spouse noted that the Veteran stopped going to church, had lost interest in visiting his family, having recently had a relapse, and was fragile and breaks down. However, she explained that this behavior had intensified in the last 10 years. Conspicuously absent from this statement is any contention that the Veteran experienced a concrete and identifiable increase in the severity of psychological symptoms in the year leading up to his August 2015 claim that resulted in total occupational and social impairment. At the time of a December 2014 VA clinical examination, the Veteran again reported intrusive thoughts, nightmares, irritability, a depressed mood, and a tendency to isolate or snap at his wife. However, the clinical signs and findings again fail to rise to the level of severity contemplated by the criteria for a 100 percent evaluation. Rather, he was found to be well groomed, alert and oriented, and have normal speech. Although he was irritable with a mildly restricted affect at that time, he also had good insight, intact judgment, and no abnormalities in his thought process or content. Largely similar psychological examination reports appear in the remainder of the psychiatric treatment records leading up to August 2015, including in March, April, and May of that year. In February 2015, the Veteran was afforded a contract psychological examination. At that evaluation, the examiner noted that the Veteran had presented with “severe” symptoms of PTSD and attributed depression, anxiety, irritability, social withdrawal, and re-experiencing of traumatic events to that disability. Other symptoms identified included suspiciousness, panic attacks occurring weakly or less often, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, a flattened affect, and chronic sleep impairment. In addition, the Veteran also was noted to have symptoms of difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, suicidal ideation, and impaired impulse control, such as unprovoked irritability with periods of violence. These symptoms would appear to represent substantially severe impairment and the Board finds that the examiner is clearly competent to report on these clinical manifestations of the Veteran’s PTSD. However, these severe symptoms appear to stand in sharp contrast with the largely mild clinical reports from treatment visits that occurred both shortly before and after that February 2015 examination. For instance, in a psychiatric care note from March 2015, the Veteran did report intrusive nightmares, mood disturbance, irritability, and a recent PTSD exacerbation that led him to want to isolate himself and move into the woods. Nightmares also reportedly occurred four times per week. Yet despite those abnormalities, there was no mention of the violent outbursts reported at the February 2015 psychological examination. Clinical signs reported by the Veteran’s treating physician at that time also appear inconsistent with the severity described at the February 2015 examination. The Veteran was reported to have normal speech, an only mildly restricted affect, calm behavior, and a well-groomed appearance. The Veteran also had good insight, intact judgment, and grossly intact cognition. Likewise, the Veteran had logical, coherent, and goal-oriented thought processes and neither suicidal nor homicidal ideation. Treatment records from shortly after the Veteran’s February 2015 examination also appear to indicate that any suicidal ideation present at that evaluation were fleeting. Given the mention of suicidal ideation at the February 2015 evaluation, treating clinicians reportedly reached out to the Veteran due to follow up on those serious symptoms. The Veteran reportedly explained that a recent treatment session involving prolonged exposure in January 2015 had so distressed him that he began to have thoughts of ending his life. However, he also stated that that period of distress lasted only a couple of weeks and had since declined to the point that by late February 2015 he no longer was having any suicidal ideation and was in fact feeling overall much better. Ultimately, the Board finds that the numerous and largely moderate nature of the signs and symptoms documented in the Veteran’s treatment records represent the most probative evidence with respect to the Veteran’s claim. They nearly uniformly lack the type or severity of symptom that are identified in the General Rating Formula and fail to demonstrate any specific factually ascertainable point in the year leading up to the Veteran’s August 2015 claim for a TDIU that would indicate that the Veteran’s PTSD symptoms had increased in severity such that they caused total social and occupational impairment. Taken with the repeated competent statements of the Veteran and his spouse that the severity of his symptoms had not significantly changed since 2012, the Board finds that the preponderance of the probative, credible, and competent evidence of record is against a finding that an earlier effective date pursuant to 38 C.F.R. § 3.400(o)(2) is warranted. As such, the Veteran’s claim for an earlier effective date for the 100 percent evaluation for PTSD must be denied and the doctrine of the benefit of the doubt is inapplicable to the Veteran’s claim. 3. Entitlement to a total disability rating based on individual unemployability for the period prior to August 12, 2015 In his August 2015 claim form, the Veteran also sought entitlement to a TDIU based on the limiting effects of his service-connected prostate cancer and PTSD. As a claim for a TDIU is a form of a claim for an increased evaluation, the assignment of an effective date for an award of a TDIU is governed by the statutes and regulations governing the assignment of effective dates for an award of an increase compensation as discussed above. See e.g. Buie v. Shinseki, 24 Vet. App. 242 (2010). Accordingly, for reasons identical to those explained in the Board’s discussion of the effective date of a total rating for the Veteran’s PTSD, the Board is precluded as a matter of law from granting an effective date for the Veteran’s eventual award of a TDIU earlier than a year before he filed his claim on August 12, 2015. To assign such a date, the evidence must demonstrate that it was factually ascertainable that an increase in severity had occurred such that the criteria for a TDIU were met in that year. A finding of total disability is appropriate “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” See 38 C.F.R. §§ 3.340(a)(1), 4.15. In Faust v. West, 13 Vet. App. 342 (2000), the United States Court of Appeals for Veterans Claims (Court) defined “substantially gainful employment” as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran’s earned annual income. The determination as to whether a total disability rating is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-32 (1991). In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a Veteran is entitled to a TDIU is whether his or her service-connected disabilities, alone, are of sufficient severity to produce unemployability. Neither non-service-connected disabilities nor advancing age may be considered. 38 C.F.R. § 4.19. The ultimate issue of whether a TDIU should be awarded is not a medical issue, but rather is a determination for the adjudicator. See Moore v. Nicholson, 21 Vet. App. 211, 218 (2007). VA regulations place responsibility for the TDIU determination on VA, and a medical examiner’s opinion as to the employability of a particular claimant is not binding on VA. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). In deciding whether a TDIU may be awarded, an adjudicator must first evaluate the severity of a veteran’s service-connected disabilities. A TDIU 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 a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Here, the Veteran’s PTSD has been assigned a 70 percent schedular evaluation for the entire period on appeal and he has therefore satisfied the schedular requirements for a TDIU. 38 C.F.R. § 4.16(a). The limitations of the Veteran’s PTSD with respect to the year leading up to August 12, 2015, are discussed above. Although the Board does not find that it is factually ascertainable that those signs and symptoms had worsened at a specific time in that year such that the Veteran had total occupational and social impairment due to his PTSD, the Board does ultimately find that it is factually ascertainable that the effects of his service-connected disabilities precluded him from securing and following a substantially gainful occupation as of August 12, 2014. At a July 2015 medical examination, the Veteran explained that he had to wear pads due to his urinary leakage, that dripping had become an issue and required the usable of absorbent material that is changed more than four times per day, and that his recurring urinary leakage caused an odor. The Veteran also indicated his daytime voiding interval was less than one hour and, although he did not need an appliance, he stated that he had marked hesitancy and leakage. The functional impact of this service-connected disability identified in that examination report was the need to be in a controlled area where the Veteran was able to urinate when he needed. The Veteran is competent to report these clearly observable symptoms and the Board has no reason to doubt the sincerity or credibility of his contentions. In contrast to the evidence regarding the Veteran’s PTSD, which includes numerous competent reports that the severity of that disability was unchanged since he initially filed his claim for benefits in 2012, a review of the Veteran’s treatment records suggest that August 2014 was the period during which the Veteran experienced an increase in his prostate-related symptoms. Specifically, a VA treatment note from October 2014 includes a competent and credible report from the Veteran that an increase in the leakage of his urine had occurred two months prior and required him to go through several pads per day. At a psychological evaluation conducted less than two weeks later, the Veteran explained that he had to be near to or have access to a restroom at all times and again reported having to wear a pad or paper towels due to urinary symptoms. The Board finds that the Veteran’s competent and credible statements regarding both the degree of discomfort and functional limitations regarding his prostate-related urinary symptoms and the contemporaneous statement from October 2014 regarding the onset of this increase in symptoms are entitled to significant probative weight. Viewed in conjunction with the limitations caused by the Veteran’s service-connected PTSD, the Board finds that as of August 12, 2014, the limitations requiring constant access to a restroom, the need to take restroom breaks on a more than an hourly basis, and the social difficulties caused by the Veteran’s probative and competent reports of odors relating to urine leakage would have prevented him from securing and following any substantially gainful occupation. As such, the Board finds that it is factually ascertainable that the criteria for a TDIU were met as of that date and the Veteran’s claim must be granted. The Board must again note, however, that it is precluded from granting any effective date earlier than August 12, 2014, for a TDIU pursuant to 38 C.F.R. § 3.400(o)(2). REASONS FOR REMAND Entitlement to service connection for a low back disability and a left ankle disability is remanded. In the course of the instant appeal, the Veteran was provided medical examinations in February 2015 to evaluate the nature and etiology of any current low back and left ankle disability. The examiner who evaluated the Veteran at that time ultimately opined that his current orthopedic disabilities were less likely than not due to or arose in active duty service. However, the rationale provided by that examiner appears to be fairly conclusory in nature and does not address at any length the question of whether the Veteran’s in-service injuries to both his back and left ankle could have caused the subsequent development of either current disability. Instead, it appears to vaguely cite the contributing factors of multiple post-service injuries without pointing to any evidence in the claims file documenting any such injury. Accordingly, the Board does not find that those examinations are adequate for VA’s purposes and the Veteran should be afforded the opportunity to attend an additional medical evaluation upon remand. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current low back or left ankle disability. (a.) With respect to the low back disability, the examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s in-service duties requiring him to drive on bumpy roads and the in-service documentation of back-related symptoms. The examiner is asked to specifically consider the question of whether those in-service symptoms or injuries could have caused the subsequent development of his current low back disability. (b.) With respect to the left ankle disability, the examiner must opine whether it is at least as likely as not related to the Veteran’s in-service ankle injury. The examiner is asked to specifically consider whether the Veteran’s current symptoms (Continued on the next page)   represent a continuation of left ankle instability that began in service or whether those in-service symptoms or injury caused the subsequent development of any current left ankle disability. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Whitelaw, Associate Counsel