Citation Nr: 18152347 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 10-22 220 DATE: November 21, 2018 ORDER Entitlement to a rating higher than 20 percent for type II diabetes mellitus is denied. Entitlement to a rating higher than 50 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a rating higher than 10 percent for left knee disability is denied. Entitlement to a compensable rating for duodenal ulcer is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to the service-connected disabilities is denied. REFERRED The issues of entitlement to service connection for a gall bladder condition, an aneurysm, and a rash were raised in an August 2018 statement and are referred to the Agency of Original Jurisdiction (AOJ) for adjudication. FINDINGS OF FACT 1. The most probative evidence shows that the Veteran’s diabetes mellitus requires a prescribed oral glycemic agent and a restricted diet but no regulation of activities. 2. The Veteran's PTSD is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; deficiencies in most areas is not demonstrated. 3. The Veteran’s left knee disability is manifested by intermittent pain, full extension, and flexion limited to 135 degrees; flexion limited to 30 degrees is not shown. 4. Throughout the appeal period, the Veteran’s ulcer has been asymptomatic; recurrent symptoms once or twice a year is not shown. 5. The evidence does not support a finding that the Veteran is unable to secure and maintain substantially gainful employment due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 20 percent for diabetes mellitus, type II have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. § 4.119, Diagnostic Code 7913 (2018). 2. The criteria for a rating higher than 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1 – 4.7, 4.130, Diagnostic Code 9411 (2018). 3. The criteria for a rating higher than 10 percent for left knee disability have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1 – 4.7, 4.118, Diagnostic Codes 5099-5010 (2018). 4. The criteria for a compensable rating for duodenal ulcer have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. § 4.114, Diagnostic Code 7305 (2018). 5. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.7, 4.16 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from December 1955 to December 1968. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Diabetes The Veteran appeals the denial of a rating higher than 20 percent disabling for diabetes mellitus type II. Pursuant to the rating schedule, diabetes is evaluated as follows: requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet (20 percent); requiring insulin, restricted diet, and regulation of activities (40 percent); requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated (60 percent); and requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated (100 percent). 38 C.F.R. § 4.119, Diagnostic Code 7913. To warrant the next higher evaluation for diabetes mellitus, the evidence must show that the Veteran’s diabetes mellitus requires insulin, a restricted diet, and regulation of activities. There is no dispute that the Veteran's diabetes mellitus requires an oral hypoglycemic agent and a restricted diet. The Board must determine, however, if there is a showing that his diabetes mellitus requires the regulation of activities in conjunction with the use of an oral hypoglycemic agent and a restricted diet. “Regulation of activities” has been defined as the situation where the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining “regulation of activities,” as used by VA in Diagnostic Code 7913). Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360 (2007). Upon consideration of the evidence of record, the Board finds that a rating higher than 20 percent is not warranted for the Veteran’s service-connected diabetes. On this record, the Veteran is not shown to require regulation of activities in order to manage his diabetes. Throughout the appeal period, the Veteran has been afforded several VA examinations in order to accurately ascertain the severity of his diabetes. The Veteran’s diabetes has been managed primarily through diet and a prescribed oral hypoglycemic agent. There is no evidence that the Veteran has been prescribed restriction of activities on account of his diabetes mellitus. He visited his diabetic care provide less than twice a month. He did not have any hospitalizations or unintentional weight loss or loss of strength due to diabetes. See VA Examination Reports dated April 2007, November 2007, July 2008, August 2009, April 2014, and January 2017. The Veteran’s medical treatment records are also silent for any required restriction of activities due to the Veteran’s diabetes. The Board has also considered the Veteran’s lay statements of records, including the April 2016 statement that he has been seen monthly for episodes of ketoacidosis and hypoglycemia. The Veteran’s own personal opinion is not competent on the medical issue of the need to regulate activities due to diabetes mellitus. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, the Board finds the more probative evidence is against a finding that his diabetes mellitus requires regulation of activities as contemplated by the rating schedule. Rather, the more probative evidence shows that regulation of activities is not part of medical management for the Veteran’s diabetes mellitus. VA examinations and outpatient treatment records do not indicate the Veteran’s diabetes mellitus is so severe or difficult to control that he must avoid strenuous occupational and recreational activities. Examinations also show that the Veteran has never been hospitalized for episodes of ketoacidosis or hypoglycemic reactions. In light of the above, the Board must conclude that the criteria for an evaluation higher than 20 percent disabling for diabetes mellitus have not been met. PTSD The Veteran’s PTSD is rated under Diagnostic Code 9411. All psychiatric disorders are evaluated under a general rating formula for mental disorders. 38 C.F.R. § 4.130. Under the general rating formula, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for 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 situations (including work or a work-like setting); and inability to establish and maintain effective relationships. Finally, a total schedular rating of 100 percent is warranted when the disorder results in 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 mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, all ratings in the general rating formula are associated with objectively observable symptomatology, and “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). Further, “§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” Id. Thus, “[a]lthough the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in ‘most areas.’” Id. at 118. As such, the Board will consider both the Veteran’s specific symptomatology as well as the occupational and social impairment associated with the rating code to determine whether an increased evaluation is warranted. The nomenclature employed in the portion of VA’s Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as “DSM-IV”). 38 C.F.R. § 4.130. The Board notes that DSM-IV has been recently updated with a Fifth Edition (DSM-V). Effective August 4, 2014, VA issued an interim rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with DSM-V. The provisions of the interim final rule only apply, however, to all applications for benefits that are received by VA or that are pending before the AOJ on or after August 4, 2014. The claim on appeal was originally certified to the Board in December 2009. Thus, the claim was not pending before the AOJ after August 2014 and DSM-IV technically applies. Turning to the facts of the case, mental health treatment records reflect the Veteran’s reports of anxiety, flashbacks, nightmares, and sleep impairment. He also indicated episodes of anxiety and stated that his depressed mood fluctuated. He denied suicidal or homicidal ideation. See VA Treatment Records dated June 2008 through August 2008. At the October 2008 VA examination, the Veteran reported having increased anxiety and sleep disturbances, along with depression three to four days a week. He maintained a close relationship with his wife, step-children and step-grandchildren, as well his brothers. He did not socialize or maintain friendships outside of his family members. He spent most of his days engaged in solitary pursuits due to his increased anxiety in crowds. Upon mental status examination, the Veteran was oriented on all spheres and endorsed fair judgment and insight. While he did have some mild memory impairments, his affect and mood were both normal. He denied having suicidal or homicidal thoughts and denied any delusions or hallucinations. He performed activities of daily living with no issue, but he limited his shopping and leisure activities in order to avoid crowds. Ultimately, the examiner opined that the Veteran’s PTSD resulted in occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. However, the Veteran was generally functioning satisfactorily with routine behavior, self-care, and normal conversation. Mental health treatment records reflect the Veteran’s reports of anxiety, flashbacks, nightmares, and sleep impairment. He also indicated episodes of anxiety and stated that his depressed mood fluctuated. He denied suicidal or homicidal ideation. See VA Treatment Records dated June 2008 through July 2009. The Veteran was afforded another VA examination in August 2009. He reported symptoms of anxiety, nightmares, irritability, and sleep disturbance. He remained close with his wife and other family members. However, he did not engage with people outside of his family and preferred to do things alone. The Veteran’s mental status examination resulted in some moderate impairment in his delay recall memory; however, his mental status was otherwise normal. He denied delusions and suicidal and homicidal thoughts. While he endorsed some issues with leisure activities due to anxiety and crowd intolerance, he did not have any other issues with activities of daily living. Ultimately, the examiner found that the Veteran’s PTSD symptoms resulted in moderate impairment occupationally and socially. Treatment records document the Veteran’s continued reports of flashbacks, nightmares, irritability, and anxiety around crowds. There were no hallucinations, delusions, or suicidal or homicidal ideations. See VA Treatment Records dated February 2010 through November 2013. At the April 2014 VA examination, the Veteran reported sleep disturbance and nightmares, causing him to sleep for about approximately four hours per night. He also reported experiencing psychological distress in response to some trauma-related cues, along with irritability and difficulty concentrating. He experienced mild memory loss and depressed mood about four days a week, with variable frequency. While he reported some feelings of hopelessness, he denied suicidal ideation. He reported feeling anxious and nervous on a regular basis, but had minimal functional impairment associated with anxiety. He reported having a great relationship with his wife. He also reported having three good friends outside of his family, with whom he socialized with twice a week. While he still experienced some anxiety with crowds, he went to church one a month. The Veteran endorsed a normal mental status examination. Treatment records document the Veteran’s continued reports of chronic sleep impairment, flashbacks, depression, nightmares, irritability, and anxiety around crowds. There were no hallucinations, delusions, or suicidal or homicidal ideations. His mental status remained normal during this time. See VA Treatment Records dated May 2014 through December 2016. Most recently, at the January 2017 VA examination, the Veteran endorsed the following symptoms: depressed mood, anxiety, chronic sleep impairment, mild memory loss, difficulty establishing and maintaining effective relationships, difficulty adapting to stressful circumstances, and obsessional rituals which interfered with routine activities. He reported having a good relationship with his immediate family, but indicated that he did not have many close friends aside from his family. His usual daily activities included going to the senior center to socialize. He reported having nightmares and intrusive thoughts two to three times per week, along with irritability and anxiety. He avoided crowds and loud noises, as they resulted in intense physiological and psychological distress. The Veteran’s mental status examination was normal and he denied having any suicidal or homicidal ideation, delusions, or hallucinations. Ultimately, the examiner found that the Veteran’s PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. However, the Veteran was generally functioning satisfactorily with normal routine behavior, self-care, and conversation. Upon review of the evidence, the Board finds that the frequency, duration, and severity of the Veteran’s PTSD symptoms are adequately contemplated by the currently assigned 50 percent rating. Throughout the appeal period, the Veteran’s PTSD has manifested in nightmares, flashbacks, chronic sleep impairment, periods of depression, and anxiety. He has also endorsed mild memory loss and periodic irritability. While he avoided crowds and loud noises, he maintained a good relationship with his wife and family members and socialized several times a week at the senior center. During this time, his mental status was relatively normal. While his mood ranged from normal to irritated to depressed, he consistently endorsed good judgment, insight, and speech. He was always oriented on all spheres and described as alert and attentive. There was never any evidence of psychosis or hallucinations, and the Veteran always denied suicidal and homicidal thoughts or ideations. Although he was periodically depressed, there is no evidence that his symptoms significantly impacted his ability to function independently. Notably, examiners found that the Veteran’s level of impairment resulted in some decrease in efficiency and ability to perform tasks, but overall, the Veteran was functioning satisfactorily. Comparing the Veteran’s symptoms to the applicable diagnostic code, the Board finds that the symptoms more nearly approximate that which is contemplated by the 50 percent rating criteria, as the frequency, duration and severity of the Veteran’s symptoms are not indicative of impairment with deficiencies in most areas. A higher rating is not warranted. Left Knee In determining the degree of limitation of motion of a musculoskeletal disability, the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the veteran’s ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran’s knee disability is rated 10 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5010. Diagnostic Code 5010 provides that arthritis due to trauma is to be evaluated as degenerative arthritis pursuant to Diagnostic Code 5003. Under Diagnostic Code 5003, degenerative arthritis substantiated by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Turning to the facts of the case, at the August 2009 VA examination, the Veteran reported having periodic pain in the left knee, for which he took Motrin. Range of motion testing revealed flexion to 125 degrees and normal knee extension. There was no objective evidence of pain with active motion on the left side, nor was there additional limitations after three repetitions of range of motion. Upon examination, there was no evidence of deformity, giving way, instability, stiffness, weakness, incoordination, decreased speed of joint motion, episodes of dislocation or subluxation, locking, effusions, inflammation, or flare ups. While the Veteran’s knee disability limited him to standing for 30 minutes or less, there was no limitation in his walking. There was no joint ankylosis nor was there any evidence of crepitation, clicks, snaps, grinding, or any other knee abnormalities. The knee disability did not have any effect on the Veteran’s usual daily activities. Treatment records document the Veteran’s left knee arthritis and his complaints of intermittent pain. Most often, the Veteran denied any swelling, giving out, locking up, or redness and indicated that he took ibuprofen when needed, which was about 3 to 4 times per week. See VA Treatment Records from 2009 through September 2013. At the April 2014 VA examination, the Veteran reported intermittent pain in his left knee, for which he took Motrin. The Veteran stated that his knee pain came when he twisted his left leg; he was able to go up and down stairs and squat with no pain. Range of motion testing revealed flexion to 135 degrees and extension to 0 degrees with no evidence of painful motion. The Veteran was able to perform repetitive use testing with three repetitions with no additional limitation in range of motion or functional loss/impairment. Muscle strength was normal and there was no evidence of pain on palpation, tenderness, or ankylosis. At the January 2017 VA examination, the Veteran denied having pain in the left knee and reported that he was able to walk on the treadmill daily. Upon range of motion testing, both knees exhibited flexion to 135 degrees and extension to 0 degrees. The examiner did not note any pain on examination or with weight bearing. There was some localized tenderness on the medial aspect of the patella. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional functional loss or range of motion after three repetitions. There was no ankylosis present and muscle strength was normal in the left knee. The Veteran indicated that his left knee was no worse off than before. Both knees revealed no pain with passive motion and there was no evidence of pain when the left knee was used. Based on the evidence outlined above, a rating in excess of 10 percent is not warranted for the service-connected left knee disability. The Veteran’s left knee disability has been manifested by intermittent pain, full extension, and flexion limited to 135 degrees. Limitation of flexion to 30 degrees or limitation of extension to 15 degrees is not shown on this record. The Board has considered functional impairment. While he takes over-the-counter pain medication as needed, he can squat and go up and down the stairs with no issue and walk on the treadmill daily. The Board finds that the current 10 percent rating adequately contemplates the Veteran for his knee pain and any resultant functional loss. As the requisite limitation of motion or functional equivalent thereto is not demonstrated on this record, a higher rating is not warranted. Nor is the Veteran entitled to a 20 percent disability rating under DC 5003, as X-ray evidence of service-connected arthritis in two or more major joints of either leg, with incapacitating exacerbations, have not been demonstrated. The objective evidence does not demonstrate the Veteran has sought treatment for any incapacitating episodes of knee pain or loss of function during the current appeal period. The Board has also considered other potentially applicable diagnostic codes, but has found none. On this record, the Veteran’s left knee disability has not resulted in ankylosis (Diagnostic Code 5256), subluxation or lateral instability (Diagnostic 5257), dislocated or removal of the semilunar cartilage (Diagnostic Codes 5258 and 5259), or impairment of the tibia and fibula (Diagnostic Code 5262). Finally, the Board finds that the Veteran’s knee symptoms have been stable throughout the appeal period and therefore staged ratings are not appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Accordingly, as limitation of flexion to 30 degrees or limitation of extension to 15 degrees, or the functional equivalent, is not shown, a rating higher than 10 percent is not warranted for the Veteran’s left knee disability. The claim is denied. Duodenal Ulcer The Veteran’s duodenal ulcer is rated noncompensable pursuant to 38 C.F.R. §4.114, Diagnostic Codes 7305. Duodenal ulcer is rated as follows: severe, pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health (60 percent); moderately severe, less than severe but with impairment of health manifested by anemia and weight loss, or recurrent incapacitating episodes averaging 10 days or more in duration at least 4 or more times a year (40 percent); moderate, with recurring episodes of severe symptoms 2 or 3 times a year averaging 10 days in duration, or with continuous moderate manifestations (20 percent); and mild, with recurring symptoms once or twice yearly (10 percent). 38 C.F.R. § 4.114, Diagnostic Code 7305. Upon review of the evidence, the Board finds that a compensable rating for the service-connected duodenal ulcer is not warranted. Throughout the appeal period, the Veteran’s ulcer was asymptomatic. At the VA examinations, the Veteran did report periods of abdominal pain when nervous or anxious. However, VA examiners found that the Veteran’s pain was not related to his ulcer, but rather are due to an unrelated ventral hernia. See VA Examination Reports dated April 2014 and January 2017. The Veteran consistently denied having nausea, vomiting, or diarrhea and there was no history of hospitalization, surgery, trauma, neoplasm, or periods of incapacitation due to the duodenal ulcer. The was no evidence of significant weight loss, malnutrition, or anemia. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran’s symptoms are congruent with the disability picture represented by noncompensable disability rating. Evaluations in excess of a noncompensable rating are provided for mild symptoms with recurring symptoms once or twice yearly, but the medical evidence demonstrates that those manifestations are not present in this case. Entitlement to TDIU Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and that, if there are two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16 (a). If, however, the veteran does not meet these required percentage standards set forth in 38 C.F.R. § 4.16(a), he still may receive a TDIU on an extraschedular basis if it is determined that he is unable to secure or follow a substantially gainful occupation by reason of his service-connected disabilities. 38 C.F.R. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). Thus, there must be a determination as to whether there are circumstances in this case, apart from any non-service connected conditions and advancing age, which would justify a total rating based on unemployability. See Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). Here, the Veteran is service-connected for PTSD, rated 50 percent disabling; diabetes, rated 20 percent disabling; impairment of the left knee, rated 10 percent disabling; and a duodenal ulcer, rated noncompensable. His combined disability rating is 60 percent. As he does not meet the schedular requirements for TDIU, the Board may only consider whether TDIU may be referred on an extraschedular basis. 38 C.F.R. § 4.16(b). As an initial matter, the Board notes that the Veteran failed to report for a March 2017 social and industrial survey. Although he has requested another exam, he has not provided any reason for his absence. See August 2018 Correspondence. VA no longer obtains social and industrial surveys when developing TDIU claims. In any event, for the reasons discussed below, the Board finds that the evidence is adequate for rating purposes. The Veteran’s post-service work history indicates that he worked as a coal miner for 20 years until his retirement in 1995. Throughout the record, the Veteran has stated that he stopped working due to “medical reasons.” SSA found the Veteran disabled effective July 1993 due to a mood disorder. At the October 2008 VA examination, the Veteran stated that while working, he was a reliable, productive and efficient employee. He stated that he worked independently and had little contact with others, which increased good work performance. He had no history of disciplinary problems. However, he stated that he had a history of low frustration tolerance that resulted in frequent irritability. The examiner found that while the Veteran’s PTSD did result in some functional impairment, he was not unemployable due to his PTSD symptoms. The examiner also found that the Veteran’s ulcer, diabetes, and left knee had no effect on occupational activities. An August 2009 VA PTSD examination found moderate impairment in capacity for occupational and social functioning. In January 2017, a VA examiner found that the Veteran’s left knee disability did not impact his ability to perform any type of occupational task. In September 2017, a VA physician reviewed the claims file and opined that the Veteran’s diabetes, left knee strain, and ulcer disease “do not affect [his] ability to work in any occupational environment.” The examiner explained that the Veteran’s diabetes is in excellent control with no complications, he has minimal symptoms with respect to his left knee, and has no symptoms related to his remote duodenal ulcer. The Board finds that the Veteran’s service-connected disabilities, alone, do not preclude substantially gainful employment. Throughout the appeal period, his diabetes, ulcer and left knee have caused little to no functional impairment. In addition, the Veteran’s own statements reflect that while he did have some irritability on the job, his PTSD did not significantly impact his ability to work. While he described some impairment due to his PTSD symptoms, the severity of his symptoms is insufficient to establish that PTSD prevents him from working. Indeed, the impairment caused by the Veteran’s PTSD is adequately contemplated under the assigned disability rating. As for the remaining disabilities, multiple examiners have found that the Veteran’s diabetes, ulcer, and left knee had no impact on his ability to work. (Continued on the next page)   While the Board does not wish to minimize the nature and extent of the Veteran’s overall disability, the evidence of record does not support his claim that his service-connected disabilities, alone, render him incapable of securing and following a substantially gainful occupation. Entitlement to a TDIU is denied. REBECCA N. POULSON Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Orie, Associate Counsel