Citation Nr: 1807667 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 12-28 952 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cheyenne, Wyoming THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to an initial disability rating in excess of 30 percent for right hand sensory loss. 3. Entitlement to an initial compensable rating prior to February 23, 2015, and in excess of 10 percent thereafter, for degenerative arthritis of the right hand (formerly evaluated as separate digits of the right hand). 4. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD J. L. Burroughs, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1969 to December 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from September and November 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cheyenne, Wyoming. In May 2013, the Veteran presented sworn testimony during a Travel Board hearing in Cheyenne, Wyoming, which was chaired by the undersigned. A transcript of that hearing has been associated with the claims file. Historically, a September 2011 rating decision denied service connection for bilateral hearing loss. Within this decision, the RO also granted service connection for right hand degenerative arthritis of the ring finger, post fracture, with a noncompensable rating. In November 2011, the RO granted service connection and a noncompensable rating for right thumb, index, ring, and little finger limitation of motion and a 10 percent rating for right hand sensory loss. Each assigned rating was made effective January 19, 2011. Thereafter, this matter was remanded in January 2015 for further development. While pending return to the Board, the RO issued a rating decision in May 2016 wherein the Veteran's separately evaluated digits of the hand were combined into one 10 percent rating for right hand arthritis, effective February 23, 2015 (the date of VA examination). The RO also increased the Veteran's right hand sensory loss from 10 to 30 percent, effective February 23, 2015. However, in June 2016, the RO altered this determination and made the 30 rating effective from January 19, 2011 the initial date of claim. As the maximum benefits allowable have not been awarded for the full periods on appeal jurisdiction resides with the Board. AB v. Brown, 6 Vet. App. 35 (1993). The aforementioned procedural history is reflected on the title page of this decision. FINDINGS OF FACT 1. The Veteran's currently diagnosed bilateral hearing loss is at least as likely as not related to active service. 2. The Veteran's right hand sensory loss has not manifested in: severe incomplete paralysis of the ulnar nerve of the major hand or complete paralysis of the ulnar nerve on the major hand with "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers precluding spreading of the fingers (or reverse), adduction of the thumb; flexion of wrist weakened. 3. From October 23, 2012, x-ray testing confirmed the Veteran had arthritis in multiple joints of the hand and the record confirms painful motion; and, at no point during the appeal did the Veteran's disabilities of the hand manifest in favorable or unfavorable ankylosis (other than of the little finger); loss of thumb motion resulting in a gap of at least one inch between the thumb pad and fingers; limitation of motion of the index finger with a gap of at least one inch between the fingertip and the proximal transverse crease of the palm; or have extension limited by more than 30 degrees. 4. The Veteran is not shown to have been unable to obtain or maintain gainful employment as a result of service-connected disabilities. CONCLUSIONS OF LAW 1. Bilateral hearing loss was incurred in active service. 38 U.S.C. §§ 1110, 5107 (2002); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for a disability rating in excess of 30 percent for right hand sensory loss are not met. 38 U.S.C. § 1155, 5107 (2002); 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8516 (2017). 3. The criteria for an initial 10 percent disability rating for degenerative arthritis of the right hand have been met from October 23, 2012, but no sooner; the criteria for a rating in excess of 10 percent for degenerative arthritis of the right hand have not been met for any period on appeal. 38 U.S.C. § 5103, 5103A, 5107 (2002); 38 C.F.R. § 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5003, 5010, 5227-5230 (2017). 4. The criteria for establishing entitlement to a TDIU are not met. 38 U.S.C. § 1155, 5107 (2002); 38 C.F.R. § 3.321 (b)(1), 4.16(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Assist and Notify As the Veteran's claim for service connection for bilateral hearing loss is granted herein, any error related to the VA's duty to notify and assist is moot. 38 U.S.C. §§ 5103, 5103A (2002); 38 C.F.R. § 3.159 (2017); Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Since the May 2016 Remand, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist with regard to the Veteran's claim for increase rating of the hand/finger. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). However, with specific regard to entitlement to TDIU the Veteran, by way of his representative, has asserted that the February 2015 and 2016 VA examiners failed to comply with the Board's Remand directives. See Representative Brief Presentation Received January 2018. In pertinent part, the Board directed that an opinion be obtained on "whether the Veteran's service-connected right hand and finger disabilities, individually or in concert, preclude him from engaging in substantially gainful employment." The Veteran essentially contends that the examiners did not truly analyze his disabilities impact on his employability. Instead, the examiners "appear to only list and recommend limitations and accommodations the veteran would need to maintain employment." The Board does not find the Veteran's argument persuasive. Addressing the 2016 peripheral nerve examination opinion first, the examiner opined that the Veteran's hand disabilities did not impact employment. With regard to the remaining opinions, the record reveals clear notations that although the Veteran's disabilities impacted his employability they did not preclude employment. The examiners supported these findings by providing probative evidence as to the types of employment possible and mechanisms by which the Veteran would still be able to function in a work environment. Finally, the Board emphasizes that the ultimate determination of employability is left to the adjudicator following consideration of the collective record. See Geib v. Shinseki, 733 F.3d 135 (Fed. Cir. 2013); Smith v. Shinseki, 647 F.3d 1380, 1385-86 (Fed. Cir. 2011). As will be discussed in detail below, the collective clinical, examination, employment and educational history, and lay evidence simply does not establish that any of the Veteran's disabilities either individually or in concert render him unemployable. Thus, a remand for a clarifying or addendum opinion is not warranted. See Soyini v. Derwinski, 1 Vet. App. 541 (1991) (finding that strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran). Service Connection Under the relevant laws and regulations, 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, 1131 (2002). Generally, 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, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). An alternative method of establishing the second and third Shedden/Caluza elements is through a demonstration of continuity of symptomatology under 38 C.F.R. § 3.303 (b), if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a). Sensorineural hearing loss is a qualifying chronic disease. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As a result, service connection via the demonstration of continuity of symptomatology is applicable. The Veteran asserts experiencing regular hazardous noise exposure in-service while fulfilling his duties as an aircraft mechanic, gunner, crew chief, and repairman. See Board Hearing Transcript. As indicated in the Board's prior remand, he has also competently reported experiencing diminished hearing since service. Turning to the record, August 2011 and February 2016 VA examination reports confirm diagnoses of bilateral sensorineural hearing loss. These reports also note, at the 4000 Hertz frequency level, auditory thresholds of greater than 40 decibels (dB). See 38 C.F.R. § 3.385. Therefore, current disability is established. Personnel records confirm that the Veteran's military occupational specialty (MOS) was "aircraft mechanic" and that he had flight status. Additionally, in December 2012 he submitted copies of flight logs indicating hours of flying time while in-service. He also submitted a buddy statement from a fellow crew chief, R. G., who confirmed his reports of flying missions and working as a gunner. Finally, service treatment records confirm the Veteran sought, but was denied, a thicker helmet for sound protection in April 1971. At that time, an in-service physician noted that he suffered from hearing loss in the right ear. Just prior to service separation he again sought treatment for an "ear problem" in August 1971. In-service noise is conceded. Accordingly, the first and second elements of Shedden/Caluza are met. What remains for consideration is whether his current hearing loss can be correlated to his in-service noise exposure. Of record are two VA examination opinions obtained in 2011 and 2016. The 2011 VA opinion was deemed inadequate by the Board in February 2015 and will not be discussed further. The Board finds the 2016 opinion is also inadequate. In relevant part, the examination report is negative for discussion or even notation of the Veteran's reports of diminished hearing since service. Additionally, the examiner failed to address the aforementioned 1971 treatment records wherein the Veteran sought hearing protection and was noted to have right ear hearing loss. In light of these omissions, this opinion is insufficient to form the basis of a denial of service connection. That said, rather than remand for yet another opinion that addresses these deficiencies, the Board finds that the evidence is, at minimum, in equipoise regarding the question of whether the Veteran's current bilateral hearing loss is related to his military service. 38 U.S.C. § 1131 (2002); 38 C.F.R. § 3.303 (2017). The third element of Shedden/Caluza can also be satisfied with a showing of continuity of symptomatology. In the instant case, since initial application for service connection the Veteran has asserted hearing loss since service. See January 2011 VA 21-526 Veterans Application for Compensation or Pension. His spouse also testified that when they met in 1979 the Veteran was already suffering from what could be construed as hearing impairment. His hearing had diminished to the point of being unable to understand others unless directly facing them. The Board finds these statements credible, reasonable, and sufficient to support the Veteran's report of hearing loss since service. Further, there is no competent clinical evidence to the contrary. In sum, although there is no positive opinion of record, the Veteran has conceded in-service injury and noise exposure, a currently diagnosed bilateral hearing loss disability for VA benefit purposes, and there is competent and credible statements/testimony indicating ongoing hearing problems since service. The benefit-of-the-doubt will be conferred in the Veteran's favor and his claim for service connection for bilateral hearing loss is granted. 38 U.S.C. § 5107(b) (2002); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Increase Rating Regulations Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C. § 1155 (2002); 38 C.F.R. Part 4 (2017). Separate DC identify the various disabilities. 38 C.F.R. Part 4 (2017). When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2017). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are appropriate for an increased rating claim, if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran is currently in receipt of a 30 percent rating, effective January 19, 2011 under DC 8516 for moderate incomplete paralysis of the ulnar nerve of the major hand. Under this DC a 40 percent rating is awarded for severe incomplete paralysis of the ulnar nerve of the major hand. A 60 percent rating is warranted for complete paralysis of the ulnar nerve on the major side; the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened. 38 C.F.R. § 4.124a, DC 8516. In addition, from January 19, 2011 until February 23, 2015 the Veteran was in receipt of noncompensable ratings for a right hand little finger condition rated under 5230; a right hand long finger condition rated under 5229, a right thumb condition rated under 5010-5228, and right hand degenerative arthritis of the ring finger, post fracture rated under 5010-5227. Thereafter, from February 23, 2015 forward, these disabilities were combined into a single 10 percent rating for right hand arthritis rated under 5228-5010. Hyphenated DCs are used when a rating under one code requires use of an additional DC to identify the basis for the rating assigned. 38 C.F.R.§ 4.27 (2017). Here, the use of DCs 5010-5227 reflects that the Veteran's right hand disability is partially described as traumatic arthritis under DC 5010 and that the rating assigned is based on ankylosis of the little finger under DC 5227. Similarly, DC 5010-5228 covers arthritis, the thumb, and limitation of motion. Arthritis due to trauma and substantiated by x-ray findings will be rated as degenerative arthritis. See 38 C.F.R. § 4.71a, DC 5010 (2017). DC 5010 instructs to rate under DC 5003 (degenerative arthritis). Under that DC, arthritis of a major joint or group of minor joints is to be rated under the criteria for limitation of motion of the affected joint. See 38 C.F.R. § 4.71a, DCs 5003, 5010 (2017). For the purpose of rating disabilities due to arthritis, the interphalangeal, metacarpal, and carpal joints of the upper extremities are considered a group of minor joints, ratable on parity with major joints. See 38 C.F.R§ 4.45 (2017). Where limitation of motion of the joint is noncompensable under the appropriate DC, a rating of 10 percent is for application. See 38 C.F.R. § 4.71a, DC 5003 (2017). With x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent rating is warranted. While the thumb is not a major joint, it is a collection of minor joints for the purposes of 38 C.F.R. § 4.45. Under DC 5227, a noncompensable rating is warranted for either unfavorable or favorable ankylosis of the little finger. 38 C.F.R. § 4.71a, DC 5227. A note to DC 5227 directs that consideration should also be given to whether a rating for amputation is warranted and whether an additional rating is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. Id. Under DC 5228, a noncompensable disability evaluation is assigned for limitation of motion of the thumb with a gap of less than one inch (2.5 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a. A 10 percent disability rating is warranted where loss of thumb motion results in a gap of one to two inches (2.5 to 5.1 centimeters) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A maximum schedular 20 percent disability rating is assigned for loss of thumb motion that causes a gap of more than two inches (5.1 centimeters) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Ratings under DC 5228 are the same, regardless of whether the disability in question involves the thumb on the major (dominant) or minor hand. Id. Under DC 5229, a 10 percent disability rating is warranted for limitation of motion of the index finger with a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible; or with extension limited by more than 30 degrees. Under DC 5230 [limitation of motion of ring or little finger] a noncompensable rating is assigned for any limitation of motion of the ring or little finger. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. § 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2017); see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Factual Background On August 2011 VA examination, the Veteran reported suffering from limited range of motion of fingers, "development of fist," and numbness to the 4th and 5th digit and tingling sensation over 3rd, 4th, and 5th metacarpal area. He reported decreasing strength in his right hand occurring over the past five years. He also reported taking retirement early due to hand issues, as his right hand was not able to accomplish fine motor tasks. Functional impairments of excess fatigability, incoordination, and less and weakened movement than normal were noted in the long, ring, and index fingers. Deformity was noted solely in the ring finger. Other impairments were a dull achy pain in the right hand that was a 2/10 in severity in the mornings rising to a maximum of 5/10 following shooting, mechanical repairs, or gardening. Examination revealed limitation of motion or evidence of painful motion in the thumb and ring finger. There was no gap between the thump pad and the finger. There was a gap of less than 1 inch between the ring finger and little finger with no objective evidence of painful motion. There was no evidence of limitation of extension or evidence of painful motion for the index finger or long finger. Repetitive testing was conducted with no additional limitation of motion noted. There was no pain on palpation. Ankylosis was present in the right 4th distal interphalangeal joint (DIP); resulting in the Veteran being unable to complete fine motor tasks with his right hand. The 4th and 5th digits had decreased touch sensation, vibration, and pin/dull sensation. There was also decreased hand strength with bilateral hand grasp, but no changes in position of the digits. The Veteran's reflexes were normal. Sensory examination revealed decreased vibration, pain/pinprick, light touch, and dysesthesia in the 3rd-5th digits from the metacarpal heads to the fingertips. There was no indication of complete or incomplete paralysis. Grip strength was 4/5. Diagnostic testing revealed that the Veteran did not have degenerative arthritis in multiple joints of the same hand. In a September 2011 addendum opinion, the examiner clarified that the Veteran's sensory loss and traumatic arthritis were the result of the service injury. The examiner also explained that the Veteran's limitations of the right hand thumb, long finger, and little finger area were caused by or a result of his service-connected right ring finger fracture with arthritis. During an October 23, 2012 private examination, the Veteran's grip strength was noted in positions I, III, and V to be 42, 51, and 49. See Primier Bone & Joint Centers Records. He also reported some generalized aching in his hand. X-rays revealed multiple sites of degenerative change. There was some arthritic change at the distal radioulnar joint (DRUJ) and mild radioscaphoid degenerative joint disease (DJD). He had a type 2 lunate. There was 5th metacarpophalangeal joint DJD and "quite a bit of ring distal interphalangeal joint DJD." On February 2015 VA hand examination, the Veteran reported that his hand strength, range of motion, pain, and numbness had gotten worse since VA examination in 2011. Flare-ups were noted to: limit his fine motor skills, driving, gripping with his right hand, and cause increase pain. Flare-ups also caused hand fatigue which required resting or switching of the right hand every 15 minutes. Physical examination reveal abnormal range of motion. Index and long fingers had max extension of the MCP, PIP, and DIP to 0 degrees and max flexion to 90, 90, and 70 degrees, respectively. Max extension of the ring finger's MCP, PIP, and DIP was to 0 degrees and max flexion was to 80, 85, and 55 degrees, respectively. The little finger had max extension of the MCP, PIP, and DIP to 0 degrees and max flexion to 80, 85, and 60, degrees respectively. On February 2015 VA nerve examination, the Veteran reported that his right hand pain, range of motion, strength and numbness had gotten worse since his August 2011 examination. Symptoms attributable to his peripheral nerve condition were moderate numbness and paresthesia and/or dysesthesia. Physical examination revealed grip and pinch strength of 4/5 indicating active movement against some resistance. Wrist flexion was 5/5 meaning normal strength. Reflex examination was normal in the biceps and hypoactive in the triceps and brachioradialis. Sensory examination revealed normal sensation in the shoulders, but decreased sensation in the inner/outer forearm and hand/fingers. Nerve impairment was only present in the ulnar nerve which had mild incomplete paralysis. Assistive devices were not required and his disabilities were not of the severity such that they were equivalent to amputation. The examiner opined that the Veteran's impairments impacted his ability to work as it limited his ability for fine motor skills. On February 2016 VA nerve examination, the Veteran reported no change in his condition since his 2015 examination. He also denied a history of surgery, constant right hand neuropathic pain, and numbness or tingling to the right hand or fingers. However, he reported intermittent dull ache occurring two to three times a week and lasting approximately two hours. Scale of symptoms was noted to be 3/10. Precipitating factors for his symptoms were prolonged gripping. He reported effects on his employment were decreased fine motor skills. Physical examination revealed no constant pain, numbness, or paresthesia and/or dysesthesias. Muscle strength and reflexes were normal. Sensory examination revealed decreased sensation to 10 gm monofilament at the dorsal right 5th finger only. Nerve impairment was only present in the ulnar nerve which had mild incomplete paralysis. Wrist flexion was 5/5 meaning normal strength. Assistive devices were not required and his disabilities were not of the severity such that they were equivalent to amputation. The examiner opined that his peripheral nerve condition did not impact his ability to work. Throughout the appeals period the Veteran has reported and testified to symptomatology including pain, decreased strength and dexterity, aching, and loss of sensation. The remaining clinical and lay evidence of record is duplicative of the aforementioned lay, clinical, and examination evidence. Analysis Review of the claims file is negative for evidence of severe incomplete or complete paralysis throughout the pendency of the appeal. Rather these records reflect that the Veteran's nerve impairment never exceeded that of moderate as found on his 2015 VA examination. Indeed, for the majority of the record, the Veteran's symptoms were considered to be only mild. There are no findings that contradict that determination. It would also be improper of the Board to attempt to draw its own medical conclusions in light of the clear medical finding. See Colvin v. Derwinski, 1 Vet.App. 171 (1991) (Board is prohibited from making conclusions based on its own medical judgment). In this regard, his 2016 examination neither reflected increase in severity nor did the Veteran report such. Therefore, entitlement to a rating in excess of 30 percent for right hand sensory loss under DC 8516 throughout the pendency of the appeal is not warranted. A separate rating under a different code is also inapplicable as the claims file is negative for other relevant nerve impairment throughout the pendency of the appeal. With regard to the Veteran's previous ratings for limitation of motion, the Board does not find that increased ratings are warranted. The Veteran is in receipt of the maximum rating available under DC 5227 and 5230, therefore increases are not applicable. A compensable rating is not warranted under DC 5228 as the record is silent for evidence of a gap between the thumb pad and the fingers. Similarly, a compensable rating under DC 5229 is not warranted as the record does not indicate that the Veteran has, at any point during the pendency of the appeal, had a gap of one inch or more between the fingertip and proximal transverse crease of the palm. That said, the Board finds that the Veteran is entitled to a 10 percent rating under DC 5010 from October 23, 2012. Per the Veteran's October 23, 2012 private examination report, he was noted to have arthritis in multiple joints of the hand and the adjoining clinical and lay evidence support painful motion. A higher rating is not warranted as the Veteran did not report, and the record does not reflect, that he had arthritis in two or more major or minor joint groups with occasional incapacitating exacerbations. A 10 percent rating prior to October 23, 2012 is not warranted as the record is silent for confirmatory x-ray evidence of arthritis in multiple joints of the hand. Of note, the x-ray evidence from August 2011 examination was negative for arthritis in multiple joints of the hand. In sum, entitlement to an initial compensable rating prior to February 23, 2015 is granted with a 10 percent rating effective October 23, 2012. However, a rating in excess of 10 percent for degenerative arthritis of the right hand or right finger/thumb limitation of motion is not warranted for any portion of the period on the appeal. Additionally, entitlement to a rating in excess of 30 percent for right hand sensory loss for any portion of the appeal is denied. The Board emphasizes that it has considered the Veteran's reports of functional limitations and symptomology, to include pain. However, the objective evidence does not support a finding that the Veteran's service connected hand pain and other symptoms have been associated with such additional functional limitation as to warrant increased compensation pursuant to the provisions of 38 C.F.R. § 4.40, 4.45, or the holding in DeLuca. To that extent, the Veteran's reported symptomology was directly incorporated with in the decision to grant his 10 percent rating. In this regard, the Board notes that the Veteran is competent to report symptoms of his hand disabilities. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). Additionally, he is credible in his reports of symptoms and their effect on his activities. He is not however competent to identify a specific level of disability of his disabilities according to the appropriate DC. Such competent evidence concerning the nature and extent of the Veteran's service-connected disabilities has been provided by medical professionals who examined him and considered the entirety of the claims file. The Board finds the examination reports, in conjunction with the clinical evidence of record, should be accorded greater weight than the Veteran's subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Lastly, consideration has been given to assigning a staged rating; however, at no time during the period in question has the disability warranted a higher schedular rating. Fenderson, 12 Vet. App. 119 (1999). Entitlement to TDIU As indicated by the Board's last remand the issue of TDIU has been raised by the record. In relevant part, the Veteran essentially testified that his right hand disabilities preclude obtaining employment in his original trade as a service specialist. Total disability will be considered to exist 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. 38 C.F.R. § 3.340. 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). The Veteran's service connected disabilities include: traumatic brain injury (TBI), evaluated as 40 percent disabling, right hand sensory loss; evaluated as 30 percent disabling, right hand arthritis, evaluated as 10 percent disabling; and posttraumatic stress disorder (PTSD); evaluated as 30 percent disabling. Additionally, by virtue of this decision, he in now service connected for bilateral hearing loss. The Board is aware that a rating has not been assigned for the hearing loss disability. Such is not prejudicial to the Veteran. This is because the Veteran already meets the schedular requirements for a TDIU despite any rating that would be assigned for hearing loss. The germane question is whether the Veteran is presently unable to obtain or maintain gainful employment as a result of service-connected disabilities. The medical opinions discussed below address that question. [Note: The Board recognizes that the rating assigned to the hearing loss disability could result in the Veteran reaching the requirements for a combined total schedular rating. However, in the event that such would occur, the TDIU issue would be rendered moot.] It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91, 57 Fed. Reg. 2317(1992). Factors such as employment history, and educational and vocational attainments, are for consideration. Assignment of a TDIU evaluation requires that the record reflect some factor that "takes the claimant's case outside the norm" of any other veteran rated at the same level. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. § 4.1 , 4.15). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or maintain employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Id. The medical evidence includes several VA DBQs indicating that although the Veteran's service connected disabilities cause some impairments they do not render him totally unemployable. On August 2011 VA hand examination, his right hand disabilities were noted to impact his ability to work. His impairments were described as an inability to complete fine motor skills with the right hand, thus limiting his ability to complete assignments and projects. On August 2011 VA psychological examination, he reported working for the gas company for nearly thirty years and experiencing no difficulty with concentration, attention, memory or other deficits. Although he specified that his wife did occasionally complain about his memory, he denied a belief that his memory caused any safety problems or impairment in his daily functioning. On August 2011 VA TBI examination, his symptoms were noted not to effect employment. Additionally, on February 2015 and 2016 VA hand examinations, the Veteran was opined to be able to complete light work and unlimited sedentary work. On February 2015 nerve examination, his neuropathies limited his ability for fine motor skills, but there was no indication that his condition precluded employment. To that end, on subsequent February 2016 peripheral nerve examination, his disabilities were opined not to impact employment. On February 2016 VA audiological examination, the examiner confirmed hearing impairments, but did not indicate that they impaired employment nor did the Veteran indicate they diminished his ability to seek employment. Notably, at the time of examination the Veteran merely noted that he was retired. On December 2016 VA psychiatric examination, the Veteran described a positive work history where he drove a tanker truck for 30 years, which was when he self-described as fully retiring 3-years later. He said he loved working for the gas company, and that he got along well with his colleagues and customers. The examiner noted that the Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversations. The examiner explained that the Veteran was not experiencing any occupational impairment due to his PTSD, rather the condition only caused a moderate level of social impairment. Finally, in an adjoining VA examination to access severity of the Veteran's TBI, an examiner opined that his disability did not impact his ability to work. Of note, on examination he reported no physical complaints associated with his TBI residuals specifically denying dizziness, headaches, and weakness. He also demonstrated normal communication and motor activity. It was also noted that the Veteran enjoyed shooting, fishing, gardening, and working on his vehicles. Based on the above, the Board finds that the Veteran's service-connected disabilities do not preclude him from gainful employment. It is clear that there are some physical and psychological limitations caused by his disabilities, including pain, diminished dexterity, hearing loss, and decreased social functioning. However, no physician has opined that these symptoms render the Veteran totally unemployable. Further, to the extent that that these disabilities impair his employment, a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. That said, generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or any illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Nevertheless, the ultimate question for TDIU is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose. The evidence does not specifically show that his disabilities preclude all forms of employment. To that point, when questioned at his personal hearing about his employment status, the Veteran did not allege that he could no longer engage in all forms of employment. Instead, he testified to being unable to engage in his original form of employment as a service specialist due to lack of dexterity in his hands. Importantly, after leaving his gas company job, the Veteran stated that he worked in a separate position as an inspector. He was able to function in this position because it did not require the physical use of his hands. It is noted that the Veteran reports in engaging in hobbies that include working on vehicles and gardening. The Board acknowledges that on February 2016 hand/finger examination the Veteran reported leaving this position due to memory issues. However, such a statement directly contradicts his Board hearing testimony wherein he specified leaving his inspector position not because of his service-connected disability symptomatology, but instead "basically because the work dried up." Lastly, when further questioned whether he believed he could obtain employment in other sectors of the work force, the Veteran indicated that his hesitation with seeking other employment was based on travel time not impairment level. In sum, the record does not support that the Veteran's service-connected disabilities render him unable to obtain or maintain substantially gainful employment. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to a TDIU is denied. See 38 U.S.C. §5107. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 , 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Entitlement to service connection for bilateral hearing loss is granted. Entitlement to an initial rating in excess of 30 percent for right hand sensory loss is denied. A 10 percent disability rating for right hand degenerative arthritis is granted, effective May 13, 2009, but no sooner. Entitlement to a TDIU is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs