Citation Nr: 18153531 Decision Date: 11/28/18 Archive Date: 11/27/18 DOCKET NO. 15-06 593 DATE: November 28, 2018 ORDER Entitlement to service connection for a sleep condition, to include sleep apnea and chronic fatigue syndrome is denied. For the entire appeal period, entitlement to a 30 percent rating for left knee instability is granted. Entitlement to a rating in excess of 10 percent for left knee anterior patellar spur is denied. Entitlement to a total disability rating based on individual unemployability is granted. FINDINGS OF FACT 1. The evidence is insufficient that the Veteran’s sleep condition had its onset in service, is related to Gulf War service, or is secondary to his service-connected mood disorder. 2. For the entire appeal period, the Veteran’s left knee condition manifested in severe instability. 3. For the entire appeal period, the Veteran’s left knee condition manifested in painful motion and forward flexion limited to no worse than 90 degrees. 4. The evidence is sufficient to show that the Veteran’s service-connected disabilities make him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a sleep condition, to include sleep apnea and chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.317. 2. The criteria for a rating of 30 percent, but no higher, for left knee instability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5257. 3. The criteria for a rating in excess of 10 percent for left knee limitation of motion have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260. 4. The criteria for entitlement to TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.314, 3.321, 3.340, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from April 1983 to July 1999. A claim for increased evaluation includes a claim for a finding of TDIU where there are allegations of worsening disability and related unemployability. Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, in connection with his IR left knee claim, the Veteran has continually asserted that he is not currently capable of full time employment. As such, TDIU is before the Board. See October 2014 Notice of Disagreement. 1. Entitlement to service connection for a sleep condition, to include sleep apnea and chronic fatigue syndrome. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish service connection for a disability, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be granted for any disease 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). Service connection may also be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Service connection may be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of chronic disability resulting from an undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on undiagnosed illness, unlike those for “direct service connection,” there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are competent to report objective signs of illness. Id. A “qualifying chronic disability” for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, or a functional gastrointestinal disorder) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). Irritable bowel syndrome is a qualifying chronic disability for purposes of 38 U.S.C. § 1117. See 38 C.F.R. § 3.317 (a)(2)(i)(B)(3). The term medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, or disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317 (a)(2)(ii). Therefore, even if a multi-symptom illness has a diagnosis, consideration should still be given as to whether the disability has no known etiology, or has a known, partially understood etiology. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b) (emphasis added). In the present case, the Veteran served in the Southwest Asia Theater of Operations during the Gulf War as shown by service personnel records. Thus, the Board finds that the Veteran is a “Persian Gulf Veteran” for the purposes of 38 C.F.R. § 3.317. See 38 C.F.R. § 3.317(e)(1). The Veteran asserts that his sleep condition to include sleep apnea and chronic fatigue syndrome are related to his Gulf War service or secondary to his service-connected mood disorder. Regarding chronic fatigue syndrome, the Veteran does not have a diagnosis. To be considered for service connection, a claimant must first have a disability. In Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. The Court has held that this requirement “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 and that a claimant may be granted service connection even though the disability resolves prior to the Secretary’s adjudication of the claim.” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); but see Romanowsky v. Shinseki, 26 Vet. App. 289, 293-94 (2013) (holding that “when the record contains a recent diagnosis of a disability prior to a veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency.”). Here, the April 2013 VA Gulf War examination indicated the Veteran did not have a diagnosis of chronic fatigue syndrome. The examiner noted that there was no documentation or pathological findings of chronic fatigue syndrome and indicated the Veteran’s sleep problems have been diagnosed as obstructive sleep apnea with excessive daytime sleepiness and insomnia related to PTSD/nightmares. In addition, medical evidence and the Veteran’s assertions consistently show that any sleep impairment other than sleep apnea is related to his service-connected mental health disabilities, which are contemplated in his evaluation for PTSD. See April 2013 VA Examination. Thus, service connection for chronic fatigue is not warranted. However, the evidence shows a diagnosis of sleep apnea. See VA Treatment Notes. The issue is whether the Veteran’s sleep apnea had its onset in service, was caused aggravated by his service-connected mood disorder, or is otherwise related to service. To this end, the preponderance of the evidence is against the claim. The Veteran’s service treatment records are silent for complaints of or treatment for sleep apnea. On his April 1999 separation report of medical history, the Veteran denied trouble sleeping. In a February 2012 correspondence, the Veteran reported that he does not sleep well at night. He reported waking up and feeling tired. He reported his condition started in 1994 or 1995. In a November 2016 VA examination, the examiner opined that the Veteran’s sleep apnea was not related to service or caused by his service-connected mood disorder. The examiner reasoned that the Veteran did not have any complaints of or evidence of sleep apnea in service. The examiner further noted that mood disorders are not a risk factor for the development of sleep apnea. Regarding aggravation the examiner stated, “Sleep apnea was not a condition that the Veteran exhibited while in service. Medications used for mood disorders however can contribute to or cause the worsening of a sleep disturbance disorder. There is no evidence in the medical record that sleep apnea was a diagnosed or treated condition.” As the examiner’s medical opinion is not responsive to whether the Veteran’s sleep apnea is aggravated by his service-connected mood disorder, the examiner’s opinion regarding aggravation is not afforded any probative value. In a January 2017 addendum medical opinion, the examiner opined that the Veteran’s sleep apnea would was not aggravated by his service-connected mood disorder. The examiner reasoned that a mood disorder could cause difficulty sleeping but would not directly cause an increase in the severity of obstructive sleep apnea. The suspected causes or associated conditions that are seen in the Veterans with sleep apnea are male sex, older age, excess weight, enlarged tonsils or adenoids, nasal congestion, excessive over bite, deviated nasal septum, menopause, large neck circumference, smoking, use of alcohol sedatives and tranquilizers, and family history. A mood disorder could cause a sleep disorder but not obstructive sleep apnea. The Board finds the November 2016 and January 2017 VA examinations and opinions probative to the question at hand. The examiner considered an accurate history, to include the Veteran’s contentions regarding the onset of her gastrointestinal symptoms. The opinion was definitive and supported by a rationale that considered the lay and medical evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, the Veteran has not presented or identified any contrary medical opinion that supports the claim for service connection. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The Veteran is competent to testify to facts or circumstances that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). It is also well established that lay persons without medical training, such as the Veteran, are not competent to provide medical opinions on matters requiring medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Whether the Veteran’s sleep apnea is related to service or a service connected disability requires medical expertise to determine. The Board finds that the most persuasive evidence of record shows that the Veteran’s sleep apnea did not have its onset in service, is not related to Gulf War service, and is not secondary to his service-connected sleep disorder. Accordingly, entitlement to service connection for a gastrointestinal disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Increased Rating Disability evaluations are determined by comparing a Veteran’s symptoms with criteria set forth in VA’s Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4 (2017). When a question arises as to which of two ratings applies under a diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran is presumed to be seeking the maximum possible evaluation. AB v. Brown, 6 Vet. App. 35 (1993). Separate ratings can be assigned for separate periods of time based on the facts found – a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The knee can be rated under Diagnostic Codes (DC) 5256-5263. 38 C.F.R. § 4.71a. Assigning multiple ratings for the Veteran’s right knee disability based on the same symptoms or manifestations would constitute prohibited pyramiding. 38 C.F.R. § 4.14. However, lateral instability and degenerative arthritis of the knee may be rated separately under DCs 5257 and 5003. VAOPGCPREC 23-97 (1997). Separate ratings may also be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same joint. VAOPGCPREC 9-2004. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. However, where the Veteran shows noncompensable limitation of motion, but painful motion and functional impairment are evident, the Veteran is entitled to a 10 percent rating. See DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995), Mitchell v. Shinseki, 25 Vet. App. 32 (2011); VAOPGCPREC 9-98. 2. Entitlement to a rating in excess of 10 percent prior to November 21, 2016 for left knee instability, and in excess of 20 percent thereafter. The Veteran asserts that his right knee instability is more disabling than reflected in his 10 percent rating prior to November 21, 2016 and in excess of 20 percent thereafter. The Veteran’s left knee instability is rated under DC 5257. Diagnostic Code 5257 provides a 10 percent evaluation requires slight recurrent subluxation or lateral instability. A 20 percent evaluation requires moderate recurrent subluxation or lateral instability. A 30 percent evaluation requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. The words “slight,” “moderate,” and “severe” are not defined in the above rating criteria. Rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The Board finds that for the entire appeal period, the Veteran’s left knee symptoms manifested in severe instability. In a February 2012 correspondence, the Veteran reported that his knee symptoms worsened. He indicated that whenever he hits an uneven surface his knee will pop out of socket. He reported significant pain. August 2012 and September 2012 VA treatment notes indicate the Veteran showed left knee instability with locking. Patellofemoral spurring was shown. There was no evidence of significant joint effusion. A September 2012 letter indicated the Veteran was schedule for left knee surgery in 2013 and is unable to climb, crawl, or bend. During the April 2013 VA examination, the Veteran reported that he reinjured his left knee in 2008 after jumping off a truck. He reported that since reinjury the left knee has recurrent dislocation of the patella associated with quick jerky or twisting motions. There was no left knee edema. The Veteran reported daily constant pain at a level of 5/10. Range of motion testing shows left knee flexion to 90 degrees with painful motion at 90 degrees. The Veteran showed extension to 0 degrees with no evidence of painful motion. The Veteran showed functional impairment due to less movement than normal and pain on movement. The Veteran showed full muscle strength. Joint stability testing showed left knee medial-lateral instability of 1+ (0-5 millimeters). The examination was negative for anterior instability and posterior instability. The Veteran showed slight patellar subluxation/dislocation of the left knee. The Veteran underwent a left knee arthroscopy with partial medial meniscectomy and left medial femoral condyle chondroplasty in May 2013. In the months following surgery, the Veteran continued to report pain and instability. See July 2013 VA Treatment Note. A July 2013 VA treatment note indicates the Veteran reported continued instability and pain. In his August 2013 notice of disagreement, the Veteran asserted that his left knee instability should be assigned the highest rating. He reported instability is constant daily. He reported extremely painful locking at least twice a day. He reported wearing a knee brace every day. The Veteran also asserted that his painful motion should be afforded the highest rating because he is in constant pain. A December 2013 VA treatment note indicates that the Veteran underwent an MRI of the left knee. The ACL graft indicates impingement from spurs. There was evidence of graft insufficiency. The Veteran underwent an examination under anesthesia. There was no effusion of the left knee. The Veteran had full range of motion. The Veteran had a positive Lachman test. The medical service provider noted that the knee was stable to varus and valgus stress in full extension and 20 degrees of flexion unlike on the preoperative examination which seemed like the Veteran had a bit of valgus instability in 30 degrees of flexion. An arthroscopic examination revealed a complex bucket-handle tear of the medial meniscus. A February 2014 VA treatment not indicated the Veteran continued to report left knee pain. On physical examination he limped and wore a knee brace. He was diagnosed with knee derangement. A January 2014 VA treatment note shows the Veteran continued to report subjective instability. His surgical incisions were well healed. He showed full active extension and flexion. A July 2014 VA treatment note indicates the Veteran continued to report instability. March 2015 VA treatment record shows the Veteran had anterior cruciate ligament (ACL) deficiency. He reported having left knee pain due to chronic ACL tear and quad weakness. A custom ACL brace was ordered for the Veteran and he was advised to participate in therapy. During the November 2016 VA examination, the Veteran reported continued pain and locking. He indicated he has not had any dislocation because he has reduced his activity. The Veteran reported he is unable to perform any vigorous physical activity and indicated he has no other impairment in his physical activity apart from excessive walking or climbing stairs. The Veteran showed full range of motion but had pain with flexion and extension. There was mild localized tenderness or lain on palpation of the inferomedial knee. There was no evidence of pain with weightbearing or crepitus. The Veteran could complete repetitive-use testing without additional loss of range of motion. The Veteran had full (5/5) muscle strength. Joint instability testing showed 2+ (5-10 millimeters) medial instability and 1+ (0-5 millimeters) lateral instability. The examination was negative for anterior instability and posterior instability. The Veteran showed frequent episodes of joint locking and joint pain due to his meniscal condition. Regarding functional impact the Veteran reported difficulty with prolonged standing, walking, climbing stairs, stooping, bending, and squatting. Based on the lay and medical evidence of record, the Board finds that for the entire appeal period, the Veteran’s left knee manifested in severe instability. The evidence indicates that the Veteran continually reported instability. He further reported recurrent patella dislocation. He was prescribed a custom knee brace which he reports wearing daily. During the April 2013 VA examination, which was prior to the Veteran’s most recent left knee surgery, joint stability testing showed left knee medial-lateral instability of 1+. The examination was negative for anterior instability and posterior instability but was positive for slight patellar subluxation/dislocation of the left knee. The postsurgery treatment records indicate the Veteran showed graft insufficiency. In addition, the November 2016 VA examination, which occurred after the Veteran’s most recent surgery indicates the Veteran still showed 2+ medial instability and 1+ lateral instability. In sum, for the entire appeal period, the Veteran’s left knee instability manifested in severe instability. Thus, a 30 percent rating, the maximum schedular rating, is warranted. 3. Entitlement to a rating in excess of 10 percent for left knee limitation of motion. The Veteran asserts that his left knee limitation of motion is more disabling than reflected in his current 10 percent rating. The Veteran’s service-connected knee disabilities are rated 10 percent disabling under DC 5260. Under DC 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. See 38 C.F.R. § 4.71a, DC 5260. Based on the evidence outlined above, for the entire appeals period the Veteran’s right knee disability manifested in no worse than painful motion and flexion to – at worse – 90 degrees. Thus, a rating in excess of 10 percent for right knee is not warranted. See DeLuca, 8 Vet. App. at 207-08; Mitchell, 25 Vet. App. at 32; VAOPGCPREC 9-98. A higher rating under DC 5260 is warranted only if there is limitation of flexion of the leg to 30 degrees. Here, the Veteran’s VA examinations show flexion limited to no worse than 50 degrees. The Board has also considered whether a higher rating is warranted under an alternative diagnostic code. However, there has been no suggestion the Veteran has ankylosis in her knee; therefore, Diagnostic Code 5256 is inapplicable. The Veteran has consistently shown full extension of the knee, so a higher evaluation under DC 5261 is not warranted. Similarly, there has not been any indication of impairment of the tibia and fibula as to warrant a rating under Diagnostic Code 5262. Finally, the evidence shows the Veteran is assigned a separate 10 percent rating for his left knee scars under DC 7804. See August 2013 Rating Decision. Under DC 7804, a 10 percent rating is warranted for one or two scars that are unstable (frequent loss of covering of the skin over the scar) or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful, with a maximum 30 percent rating warranted for five or more scars that are unstable or painful. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, DC 7805, Note (1). If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. at Note (2). As there is no evidence of three or four scars that are painful or unstable, a higher rating based on his surgical scars is not warranted. See November 2016 VA Examination Report. In sum, there is no basis for a higher schedular evaluation for the Veteran’s service-connected left knee disability. In reaching the above decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine does not apply. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to a total disability rating based on individual unemployability (TDIU). The Veteran asserts that he is unable to work due to his service-connected disabilities. Schedular TDIU may be assigned when the disabled person is determined to be unable to secure or follow a substantially gainful occupation as a result of service-connected disability or disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a). Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system 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). It is the policy of the VA that all veterans who are unable to secure and follow a substantially gainful occupation due to a service connected disability shall be rated totally disabled and that veterans who fail to meet the schedular criteria for a total disability rating shall be considered for such a rating on an extraschedular basis. 38 C.F.R. § 4.16(b). The Board is precluded from awarding TDIU on an extra-schedular basis in the first instance, but must ensure that the claim is referred to the Director of VA’s Compensation Service. Bowling v. Principi, 15 Vet. App. 1, 10 (2001). When determining whether the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disability, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran is currently service connection for a mood disorder evaluated as 50 percent disabling, left knee instability evaluated as 30 percent disabling, residual postoperative left knee scars as 10 percent disabling, left knee limitation of motion evaluated as 10 percent disabling, irritable bowel syndrome rated as noncompensable, seborrheic dermatitis rated as noncompensable, left knee scars associated with postoperative left knee and anterior patellar spur rated as noncompensable, and headaches rated as noncompensable. The Veteran’s combined rating was 70 percent. He meets the criteria for schedular TDIU. In addition, the preponderance of the evidence shows that the Veteran’s service-connected disabilities make him unable to secure and follow a substantially gainful occupation. The Veteran’s August 2012 TDIU application indicates he was last employed full-time in August 2011. His highest level of education is a high school diploma. He denied any other education or training. He reported that his last job involved ladder and stair climbing as well as crawling under homes. In a September 2012 letter, VA orthopedics nurse practitioner C.B. indicated that the Veteran was a candidate for knee surgery to take place in 2013. C.B. asserted that while awaiting surgery, he is unable to perform physical jobs that require climbing, crawling, or bending. During the April 2013 VA psychological evaluation, the Veteran reported that in 2007 he worked in insulation until he hurt his knee again in 2008. He reported he is currently thinking about being a travel agent so he can sit behind a desk because he is unable to do anything physical. The examiner indicated that the Veteran’s mood disorder caused social impairment only. The Veteran did not report occupational impairments due to mental health issues. The Veteran reported that he is unable to work due to his knee and medical documentation indicates work restrictions secondary to his knee problem. In an April 2013 VA treatment note, the medical service provider indicated that due to the Veteran’s service-connected irritable bowel syndrome he would need to have quick toilet access at work. Similarly, in the November 2016 VA examination, the examiner indicated that work production and the Veteran’s type of work would be limited because he needs to be close to a bathroom at all times due to his irritable bowel syndrome. In an August 2013 letter, C.B. indicated that due to the Veteran’s knee pain he is unable to complete the physical, manual labor type of work he is accustomed to during his career. He is also unable to perform physical jobs that require climbing, crawling, bending, etc. C.B. reported that the Veteran will be able to complete a job that is greater than 75 percent sedentary. The VA treatment records consistently show severe pain and limitation due to his left knee symptoms. The November 2016 VA examination report also indicates that due to the Veteran’s left knee condition he has difficulty with prolonged standing, walking, climbing stairs, stooping, bending, and squatting. (Continued on the next page)   The evidence consistently shows that the Veteran’s service-connected disabilities – and his left knee in particular – impact his ability to work. In addition, the Veteran’s highest level of education was completion of a high school diploma. The majority of the Veteran’s previous work experience include physically vigorous occupations such as working in construction and insulation, which he is unable to do due to his severe knee pain. Thus, the preponderance of the evidence shows that Veteran’s service-connected disabilities make him unable to secure and follow a substantially gainful occupation. TDIU is granted. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.A. Williams, Associate Counsel