Citation Nr: 1820779 Decision Date: 04/04/18 Archive Date: 04/16/18 DOCKET NO. 06-21 091 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent prior to June 3, 2009, for peripheral neuropathy, right hand. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD S. Schick, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from July 1982 to July 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The case was previously before the Board in April 2011, July 2013, April 2014, November 2014, and May 2017. The April 2011 Board decision was partially vacated in a December 2011 Order from the United States Court of Appeals for Veterans Claims (Court). The Court vacated that portion of the Board's April 2011 decision which denied entitlement to an evaluation in excess of 30 percent for the service-connected residuals of right wrist arthroscopy for the period from March 22, 2004, to June 2, 2009, and, in doing so, remanded the Veteran's case to the Board for action consistent with a November 2011 Joint Motion for Remand (JMR). Thereafter, in May 2012, the Board requested a medical opinion as to whether the Veteran was entitled to a "separate and distinct" rating for his right hand disorder for the period of March 22, 2004, to June 2, 2009. The case was returned to the Board in July 2013. The Board denied an evaluation in excess of 30 percent for the residuals of right wrist arthroscopy with severely decreased range of motion. The Board also denied a compensable evaluation for the period prior to June 3, 2009, for peripheral neuropathy of the right hand. The Board granted a 20 percent evaluation for the period beginning June 3, 2009, to June 28, 2012, for peripheral neuropathy of the right hand and granted a 30 percent evaluation for the period beginning June 28, 2012, for peripheral neuropathy of the right hand. The Board also remanded the Veteran's claim for a TDIU, stating that a VA examination was necessary. In a February 2014 Order, the Court vacated the portion of the Board's July 2013 decision which denied entitlement to a compensable evaluation for the period prior to June 3, 2009, for peripheral neuropathy of the right hand, and, in so doing, remanded the Veteran's case to the Board for action consistent with a February 2014 JMR. The Veteran did not request, and the Court did not disturb, any other portion of the Board's July 2013 decision. In a November 2017 Decision Review Officer (DRO) Decision, the Veteran was granted an initial 10 percent evaluation for peripheral neuropathy, right hand beginning August 1, 2002. The issue is reflected on the title page accordingly. The appeal has been returned to the Board for appellate review. FINDINGS OF FACT 1. For the period prior to June 3, 2009, the preponderance of the evidence shows that the Veteran's service-connected right (dominant) hand peripheral neuropathy has been manifested by moderate incomplete paralysis. 2. The Veteran has met the schedular criteria for a TDIU for the periods from May 8, 2007, until October 1, 2007, and beginning June 28, 2012; and the Veteran has not met the schedular criteria for the periods from August 1, 2002, until May 8, 2007, and from June 3, 2009, until June 28, 2012. 3. The preponderance of the evidence is against a finding that the Veteran's service-connected disabilities preclude him from obtaining and retaining substantially gainful employment for the entire period on appeal. CONCLUSIONS OF LAW 1. For the period prior to June 3, 2009, the criteria for a 30 percent rating, but no higher, for service-connected right (dominant) hand peripheral neuropathy have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.7, 4.123, 4.124a, Diagnostic Codes (DCs) 5307-8514 (2017). 2. For the entire period on appeal, the criteria for entitlement to a TDIU have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by a letter dated in April 2004. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Additionally, the duty to assist has also been satisfied. The Veteran has been provided multiple VA examinations and VA opinions in connection with his increased rating and TDIU claims, including examinations and/or opinions in December 2001, March 2002, May 2004, September 2005, June 2009, July 2012, November 2012, February 2014, November 2014, July 2014, September 2016, and May 2017. The Board has considered the adequacy of the VA examinations and opinions of record. Significantly, although the July 2014, September 2016, and May 2017 VA examiners described the Veteran's right hand as without peripheral neuropathy prior to June 3, 2009, and found that the June 2012 EMG testing was more accurate than physical examinations and the Veteran's subjective statements; the Board is the ultimate adjudicator and a VA examiner's assessment of a Veteran's symptoms is not dispositive as it is within the province of the Board to evaluate the probative weight of evidence in light of its own inherent characteristics and its relationship to other items of evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (acknowledging Board's authority to assign weight and probative value to evidence). Importantly, the Board also notes that the July 2014, September 2016, and May 2017 VA examiners acknowledged that the Veteran consistently reported numbness and tingling as well as subjective reports of pain. The Board acknowledges that the May 2017 VA examiner did not opine as to the severity; however, regardless of the examiner's ultimate conclusions, the May 2017 remand was warranted in order to resolve a deficit in the record with regard to symptoms associated with the Veteran's right hand peripheral neuropathy prior to June 3, 2009. In this regard, the Board finds that when evaluated in its entirety, the record is sufficient for rating purposes and when evaluated as a whole, the record is more probative than the July 2014, September 2016, and May 2017 VA examiners' opinions. See Id. Moreover, as will be discussed in more detail below, the Board observes that although the use of the terms "mild," "moderate," and "severe" by VA examiners and others is evidence to be considered by the Board, it is not dispositive of the issue and all evidence must be evaluated in arriving at a decision regarding an increased rating. See 38 U.S.C. § 7401; 38 C.F.R. §§ 4.2, 4.6. Thus, the Board finds that when evaluated in its entirety, the record is sufficient for rating purposes. II. Increased Rating Legal Criteria Disability ratings are determined by applying the rating criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule) and represent the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA compensation as well as the whole recorded history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; see generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating is assigned. Id. Additionally, while it is not expected that all cases will show all the findings specified, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. The Board has considered whether separate ratings for different periods of time are warranted based on the facts, which is a practice of assigning ratings that is referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). Factual Background A December 2001 orthopedic surgery report indicated that physical examination of the Veteran revealed good circulation to all digits and his skin and nails were normal. He had no obvious sensory disturbances in any of the fingers. He had good strength in the anterior interosseous ulnar and median nerve as well as radial nerve distributions in his hand. Tinel's and Phalen's sign were negative and there was no obvious atrophy. There was a positive Watson's sign at both wrists with the right more severe than the left. There was no obvious pain with lunotriquetral ballottement on the left or right wrist; however, there was some tenderness to palpation at the volar triangular fibrocartilage (TFC) on the right wrist. The Veteran was afforded a March 2002 VA examination and the report indicated the Veteran reported residual pain after his January 2002 surgery. On physical examination he had positive Watson's sign bilaterally. The Veteran had a significant amount of decreased range of motion in his dominant (right) wrist which caused him a moderate amount of physical impairment. A December 2002 VA physician's note indicated the Veteran underwent EMG nerve studies that did not show nerve damage. A June 2003 VA ambulatory care outpatient note indicated the Veteran reported right wrist problems. He stated that he has found it is interfering with work. He works in a specialized unit taking care of youth ages12 through 21 who have anger/psychiatric problems. They can become explosive and require restraints. He stated that once he has to do this he ends up having significant pain in the right wrist with swelling for several days and reported that his wrist always felt partly numb. He stated that he is able to hold on to objects since his past procedure. Physical examination revealed he had 5/5 grip strength. In a March 2004 Statement in Support of Claim, the Veteran reported that his right wrist condition with arthritis had worsened and he could not hold a cup of coffee with his right hand because of his wrist. He reported that he was required to write evaluations at work and his wrist locked up after a few minutes. He indicated that at night, his right wrist went numb. In an April 2004 correspondence, private doctor, Dr. A.R., indicated that the Veteran continued to have some problems with stiffening and pain in his wrist and that his wrist bothers him at work if he is involved in "holds" with the residents. The Veteran was afforded a May 2004 VA joints examination and the examiner diagnosed the Veteran with degenerative changes, right wrist, status post arthroscopy of the right wrist and torn scapholunate ligament. The examination report indicated a December 2002 magnetic resonance imaging (MRI) of the Veteran's right wrist revealed tear of the scapholunate ligament and posterior osteophytic spurring with the proximal end of the lunate which might have been related to distant trauma and a January 2002 electromyography (EMG) of the upper extremity was normal. His physician, Dr. B.H. stated that it was likely he would have to have a future wrist fusion. The Veteran reported flare-ups at least four times a week and pain and swelling due to extra activity. He reported having difficulty holding a cup and writing. He reported that he has had to give up a lot of activities due to wrist pain. He does not use any assistive devices. The Veteran is able to carry out his daily activities without assistance. He reported that his family had to help him with choirs around the house such as snow blowing, grass mowing, and trimming. Physical examination revealed he was very protective of his right wrist; he held it stiffly and did not make any unnecessary movements; there was no deformity; there was no abnormal color; there was no muscle atrophy; there was no crepitus; and there was no edema. He had significant pain with range of motion and decreased grip strength. Repetitive testing flexing, extending, pain, weakness, fatigability, and incoordination showed no change. An August 2004 private treatment not indicated the Veteran was working and physical examination notes indicated he lacked palmar and dorsiflexion and had pain throughout central palpitation of the scapholunate and radiolunate joints. The impression was chronic wrist pain, loss of motion, and possible need for fusion. The Veteran was afforded a September 2005 VA joints examination and the report indicated that the Veteran reported right wrist aches and sharp pain with any activity. Physical examination of the right wrist revealed no deformity, no sensory deficit, decreased grip strength compared to the opposite hand, severely decrease range of motion with pain on range of motion. A May 2007 private orthopedic treatment note indicates the Veteran reported wrist pain after he suffered a fall at work which was possibly consistent with the etiology of his scaphoid injury and July 2007 notes indicate he had some tenderness over the dorsal scaphoid, but Watson's test was stable now without significant tenderness. There was some pain with ulnar loading and his neurovascular exam was intact. The July 2007 private orthopedic note also indicated that he was still too tender to work and would be kept from working for the next six weeks. The Veteran was afforded a June 2009 VA wrist examination and the report indicated a diagnosis of advanced degenerative joint disease of the right wrist secondary to wrist injury. Physical examination of the right wrist revealed tenderness on palpation of the dorsum and the volar aspect of the wrist at the radial aspect. Range of motion of his right wrist was reduced with the Veteran reporting pain at the extremes of motion, particularly in the radial aspect of his wrist. His motor strength of the wrist was 3/5 in all planes; his motor strength dropped to 2/5 on repetitive flexion and extension; there was deformity of the wrist; there was no crepitus palpable on motion of the wrist; and no evidence of any subluxation, dislocation, or instability of the wrist. His neurological examination of the wrist was normal. There was no evidence of any sensory deficit of the ulnar, radial, or the median nerve distribution. He had positive Tinel's sign at the wrist. He was able to touch the proximal palmar crease with all of his fingers. His finger adduction and abduction strength was 5/5. He was able to thumb oppose all fingers without any difficulties. His thumb flexion and extension strength was 5/5; flexor digitorum profundus and sublimis strength was 5/5; grip strength was 3/5; and repetitive grip strength was 2/5. He had positive Tinel's and Phalen's test at the right wrist. The Veteran's wrist joint range of motion and strength was diminished due to a complaint of pain on attempt at repetitive motion testing and the extent and degree of which is not possible to determine due to the extreme subjectivity of the exercise. In a June 2012 VA medical opinion, the examiner indicated that he did not review the entire claims file because it was unavailable from June 2012 through July 2012. The examiner opined that after reviewing the history, the examination, and assuming the accuracy of the Veteran's history, he does have a separate and distinct condition of the right wrist. He has numbness and tingling in his right hand which is consistent of neuropathy and is separate and distinct from his osteoarthritis. Based on his history, these symptoms of wrist and hand numbness started approximately 2001-2003. In a November 2012 VA medical opinion, the examiner indicated a review of the claims file was performed and examiner opined that after reviewing the history, the examination, and assuming the accuracy of the Veteran's history, he does have a separate and distinct condition of the right wrist. He has numbness and tingling in his right hand which is consistent of neuropathy and is separate and distinct from his osteoarthritis. Based on his history, these symptoms of wrist and hand numbness started approximately 2001-2003. In a July 2014 DBQ opinion, the VA examiner opined that the Veteran's peripheral neuropathy of the right hands was less likely as not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition and explained that in June 2012 he complained of numbness and tingling in the right hand and continued to complain of this during his February 2014 VA examination. The examiner further explained that, however, the Veteran had a normal EMG of the right upper extremity showing that there was not nerve dysfunction. Dr. DM in March 2007 also stated that the Veteran was neurovascularly intact. The Veteran continued to have normal neurologic exams in May and July 2007 and during surgery the doctor confirmed that the carpal tunnel and Geyon's canal were within normal limits. In September 2016 DBQ opinion, the VA examiner opined that the Veteran's peripheral neuropathy of the right hands was less likely as not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition and explained that in June 2012 he complained of numbness and tingling in the right hand and continued to complain of this during his February 2014 VA examination. The examiner further explained that, however, the Veteran had a normal EMG of the right upper extremity showing that there was not nerve dysfunction. Dr. DM in March 2007 also stated that the Veteran was neurovascularly intact. The Veteran continued to have normal neurologic exams in May and July 2007 and during surgery the doctor confirmed that the carpal tunnel and Geyon's canal were within normal limits. The examiner added that the Veteran's VA examination report was reviewed from June 2012 and EMG testing is a more accurate test than physical examination and person's subjective statements. The Veteran's EMG was normal, showing there is not nerve dysfunction. In a May 2017 DBQ opinion, the VA examiner opined that the Veteran did not have did not have peripheral neuropathy prior to June 3, 2009 and explained that the Veteran had normal nerve conduction studies which is the gold standard of diagnosing peripheral neuropathy. The Veteran's September 2012 VA examination was reviewed and the Veteran might have developed peripheral neuropathy at that point. In 2007 there were multiple exam exams showing normal nerves and neurovascularly intact. The Veteran's nerve conduction study from 2002 was normal. The Veteran stated his symptoms began prior to that point. The examiner reasserted that in June 2012 he complained of numbness and tingling in the right hand and continued to complain of this during his February 2014 VA examination. The examiner further explained that, however, the Veteran had a normal EMG of the right upper extremity showing that there was not nerve dysfunction. Dr. DM in March 2007 also stated that the Veteran was neurovascularly intact. The Veteran continued to have normal neurologic exams in May and July 2007 and during surgery the doctor confirmed that the carpal tunnel and Geyon's canal were within normal limits. The examiner added that the Veteran's VA examination report was reviewed from June 2012 and EMG testing is a more accurate test than physical examination and person's subjective statements. The Veteran's EMG was normal, showing there is not nerve dysfunction. Analysis In a December 2012 rating decision, the Veteran was granted service connection for peripheral neuropathy of the right hand and assigned a noncompensable evaluation effective August 1, 2002, and in a November 2017 Decision Review Officer (DRO) Decision, the Veteran was granted an initial 10 percent evaluation for peripheral neuropathy, right hand beginning August 1, 2002. The Veteran's peripheral neuropathy of the right hand is currently rated under DCs 5307-8514. Under DC 5307, Muscle Group VII governs function of the wrist and fingers. The muscles arising from internal condyle of the humerus: flexors of the carpus and long flexors of the fingers and thumb; pronator. A slight injury of the dominant or nondominant side warrants a noncompensable evaluation. When moderate to either the dominant or nondominant side a 10 percent rating is warranted. When moderately severe a 30 percent rating is warranted for the dominant upper extremity and 20 percent if involving the nondominant upper extremity. Under DC 5308, Muscle Group VIII governs function of extension of the wrist, fingers, and thumb; abduction of the thumb. Muscles arising mainly from the external condyle of the humerus: Extensors of carpus, singers, and thumb; supinator. A slight injury of the dominant or nondominant side warrants a noncompensable evaluation. When moderate to either the dominant or nondominant side a 10 percent rating is warranted. When moderately severe to either the dominant or nondominant side a 20 percent rating is warranted. Under 38 C.F.R. § 4.73, DC 5309 provides that as to injury of Muscle Group 9, the forearm muscles act in strong grasping movements and are supplemented by the intrinsic muscles in delicate manipulative movements. The intrinsic muscles of the hand are: Thenar eminence; short flexor, opponens, abductor and adductor of the thumb; hypothenar eminence: short flexor, opponens and abductor of the little finger; 4 lumbricales; 4 dorsal and 3 palmar interossei. A Note to DC 5309 provides that the hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc. Rating is to be made on the basis of limitation of motion, with a minimum rating of 10 percent. Under DC 8514, which pertains to paralysis of the musculospiral nerve (radial nerve), throughout the appeal period. Under DC 8514, a 20 percent disability rating is warranted for mild incomplete paralysis of either upper extremity. Moderate incomplete paralysis warrants a 20 percent rating for the minor upper extremity, and a 30 percent rating for the major upper extremity; and severe incomplete paralysis warrants a 40 percent disability rating for the minor extremity and a 50 percent disability rating for the major upper extremity. 38 C.F.R. § 4.124a, DC 8514. A 60 percent disability rating is warranted for complete paralysis of the radial nerve involving the minor upper extremity, and a 70 percent disability rating is warranted if there is complete paralysis of the major upper extremity. 38 C.F.R. § 4.124a, DC 8514. The term "incomplete paralysis" indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. Complete paralysis is demonstrated by drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; inability to extend the hand at the wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; and where supination of the hand, and extension and flexion of the elbow is weakened, and loss of synergic motion of extensors impairs the hand grip seriously. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury; the relative impairment in motor function; trophic changes; or sensory disturbances. 38 C.F.R. § 4.120. The Board finds that there are multiple neurologic symptoms attributable to the Veteran's service-connected peripheral neuropathy of the right hand disability and the AOJ recognized that by assigning the disability a hyphenated DC 5307 to 8514. As the Rating Schedule specifically provides a prohibition against pyramiding, rating of the same manifestation under different diagnoses is to be avoided; thus the Board has evaluated the Veteran's right hand peripheral neuropathy under DC 8514, which more accurately accounts for his neurologic manifestations and allows for him to receive the greater benefit under the Rating Schedule. In light of the evidence above, the Board finds that prior to June 3, 2009, the Veteran's service-connected right hand peripheral neuropathy, which is the dominant hand, has been manifested by moderate incomplete paralysis; thus warrants a 30 percent rating under DC 8514. The Board notes the July 2014, September 2016, and May 2017 VA examination reports which indicated the Veteran did not have peripheral neuropathy; however as noted above, the Veteran is currently service connected for peripheral neuropathy of the right hand. As such, the Board will consider the findings of record, to include the VA examiner's negative opinions; however the Board is the ultimate adjudicator. As noted above, the Board observes that the terms "mild," "moderate," and "severe" are not defined in the regulations and rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Although the use of the terms "mild," "moderate," and "severe" by VA examiners and others is evidence to be considered by the Board, it is not dispositive of the issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Therefore, turning to the evidence of record, the March 2002 VA examination report indicated the Veteran reported revealed that on physical examination the Veteran had positive Watson's sign bilaterally and his dominant (right) wrist caused him a "moderate" amount of physical impairment. Upon VA examination in May 2004, the Veteran reported having difficulty holding a cup and writing and physical examination revealed he decreased grip strength. A September 2005 VA examination report indicated also indicated decreased grip strength. June 2012 and November 2012 VA medical opinions indicated that he had numbness and tingling in his right hand which is consistent of neuropathy and is separate and distinct from his osteoarthritis which started approximately 2001-2003. Thus, the Board finds that Veteran's symptoms more nearly approximate the criteria for a 30 percent rating for moderate incomplete paralysis of his right, dominant wrist. However, the Board determines that for the entire period on appeal, a rating in excess of 30 percent for right wrist peripheral neuropathy is not warranted. Significantly, a June 2003 VA ambulatory care outpatient note indicated the Veteran had 5/5 grip strength. Further, upon VA examination in May 2004, physical examination revealed of the right wrist revealed there was no deformity; there was no abnormal color; there was no muscle atrophy; there was no crepitus; and there was no edema. Moreover, upon June 2009 VA examination, neurological examination was normal; there was no evidence of any sensory deficit of the ulnar, radial, or the median nerve distribution; he was able to touch the proximal palmar crease with all of his fingers; his finger adduction and abduction strength was 5/5; he was able to thumb oppose all fingers without any difficulties; his thumb flexion and extension strength was 5/5; flexor digitorum profundus and sublimis strength was 5/5; grip strength was 3/5; and repetitive grip strength was 2/5. Therefore, the Board finds that for the period prior to June 3, 2009, the evidence demonstrates that the Veteran's right hand peripheral neuropathy more early approximated a 30 percent rating, but no higher for the entire period on appeal. The Board has considered whether the Veteran is entitled to a higher or separate rating under the other diagnostic codes related to the neurological disabilities of the hand; however, no higher or separate rating is warranted. See 38 C.F.R. § 4.71a, Diagnostic Codes 5307-8514. III. TDIU Total disability will be considered to exist where there is present any impairment of mind and body that 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 the Veteran meets the schedular requirements. If there is only one service-connected disability, this disability should be rated at 60 percent or more; if there are two or more disabilities, at least one should be rated at 40 percent or more with sufficient additional service-connected disability to bring the combination to 70 percent or more. 38 C.F.R. § 4.16(a). Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). In the present case, the Veteran is currently service connected for the following disabilities: Residuals, right wrist arthroscopy with severe decreased range of motion (ROM) rated 10 percent disabling from August 1, 2012, 30 percent disabling from March 22, 2004, 100 percent disabling from August 30, 2007, and 30 percent disabling from October 1, 2007; Peripheral neuropathy, right (dominant) hand associated with residuals, right wrist arthroscopy with severe ROM rated 30 percent disabling from August 1, 2002, 20 percent disabling from June 3, 2009, and 30 percent disabling from June 28, 2012;Tinnitus rated 10 percent disabling from August 1, 2002; Left knee chondromalacia rated noncompensable from August 1, 2002, and 10 percent disabling from March 31, 2005; Chronic left (minor) wrist sprain associated with residuals, right wrist arthroscopy with severe ROM rated 10 percent disabling from May 8, 2007; Arthritis of the lumbar spine rated noncompensable from August 1, 2002, and 10 percent disabling from July 17, 2013;Amputation of the right middle fingertip rated noncompensable from August 1, 2002; Right inguinal hernia rated noncompensable from August 1, 2002; and Parasthesias of the left inferior alveolar nerve rated noncompensable from August 1, 2002. Applying the bilateral factor, the Veteran's combined evaluations for compensation are 50 percent with disabilities of the same body system satisfying the "single disability" 40 percent from August 1, 2002; 60 percent with disabilities of the same body system satisfying the "single disability" 40 percent from March 22, 2004; 60 percent with disabilities of the same body system satisfying the "single disability" 40 percent from March 31, 2005; 70 percent with disabilities of the same body system satisfying the "single disability" 40 percent from May 8, 2007; 100 percent from August 30, 2007; 70 percent with disabilities of the same body system satisfying the "single disability" 40 percent from October 1, 2007; 60 percent with disabilities of the same body system satisfying the "single disability" 40 percent from January 3, 2009; 70 percent with disabilities of the same body system satisfying the "single disability" 40 percent from June 28, 2012; and 70 percent with disabilities of the same body system satisfying the "single disability" 40 percent from July 17, 2013. Thus, the Veteran has met the schedular criteria for the periods from May 8, 2007, until October 1, 2007, and beginning June 28, 2012. He has not met the schedular criteria for the periods from August 1, 2002, until May 8, 2007, and from June 3, 2009, until June 28, 2012. For the periods where the scheduler criteria are not met, an extra-schedular rating is for consideration. 38 C.F.R. § 3.321. Entitlement to benefits on an extra-schedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). Thus, the central question that remains for the entire period on appeal is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). A Veteran need not show 100 percent unemployability in order to be entitled to a TDIU. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In this case, the Board finds the evidence shows that the Veteran has the training and skills necessary to adjust to a range of work. The Veteran has reported that his peripheral neuropathy of the hand has caused him to become too disabled to work and as of May 2007, his disability affected full-time employment. See March 2014 Veteran's Application for Increased Compensation Based on Unemployability. He reported that the most he ever earned in one year was $55,525.00 in the year 2004 as a supervisor at a residential treatment facility. Id. He reported that his employment included work a "Physical/Admin..2," working over 40 hours per week in 2006 with no time lost form illness and his highest gross earnings per month was $3,470.00; factory work, working over 40 hours per week in 2007 and his highest gross earnings per month was $2,169.00; and Admin work, working 40 hours per week from 2009 to present with no time lost from illness and his highest gross earnings per month was $5,036.77. Id. He reported that he left his last job because of his disability; he has tried to obtain employment since he became too disabled to work; he has completed four years of high school and two years of college; and completed his Associates Degree in alcohol/drug abuse counseling in 2009. Id. In a March 2004 Statement in Support of Claim, the Veteran reported that he was required to write evaluations at work and his wrist locked up after a few minutes. In an April 2004 correspondence, private doctor, Dr. A.R., indicated that the Veteran continued to have some problems with stiffens and pain in his wrist and that his wrist bothers him at work if he is involved in "holds" with the residents. With Bextra, his pain is generally controlled. The Veteran was afforded a May 2004 VA joints examination and the report indicated that the Veteran was working full-time as a child care counselor and he had not missed work recently due to his right wrist. An August 2004 private treatment not indicated the Veteran was working. In a September 2004 Correspondence from J.W., who identified himself as a professional witness, he reported that the Veteran is frequently hindered in his day-to-day duties as a child care supervisor. J.W. reported that at time, the Veteran has not been able to type reports, assist in safety holds, and carry things needed for his position and has been frequently unable to participate in activities including football and basketball in parts of his job. He reported that the Veteran is physically limited in his job duties. The Veteran was afforded a September 2005 VA joints examination and the report indicated that the Veteran had diagnoses of status post right wrist arthroscopy with degenerative changes and left knee chondromalacia. The examination report indicated that the Veteran reported functional limitations including walking with no limitation, but at the end of the day, the knee will become throbbing unable to run; fatigue with lifting; can stand for 15 to 20 minutes and then will need to stretch; pain and popping with kneeling, squatting, or stooping; needs to stretch if sitting or in a car traveling; difficulty ascending and descending stairs with a feeling of instability reported; unable to have right wrist twisting motion or vibration; unable to lift; cramping right wrist when writing; and needs to frequently rest his hand his wrist and manipulate the fingers to relieve cramping. The Veteran reported flare-ups with cold weather and increased activity that last a day which he could continue to work through the day. He was currently working as a full-time supervisor of adolescence and reported severely restricted activities that he was able to do with adolescents especially recreational activities. He tried to avoid any activities that would aggravate his wrist or knee and reported it was difficult to satisfactorily complete his job activities especially related to safety holds that would aggravate his wrist. In an April 2006 Buddy/Lay Statement, the Veteran's coworker, E.R., indicate that he worked alongside the Veteran and has witnessed the Veteran try to use a stapler and as he was doing so would drop the stapler to the floor and grab his wrist in excruciating pain. He reported that the Veteran was very worried about losing his job and avoided situations where he could be observed by the management team. He reported noticing pain in the Veteran face and cramping in the Veteran's hands from writing. The record includes a May 2007 private orthopedic treatment note indicates the Veteran reported wrist pain after he suffered a fall at work which was possibly consistent with the etiology of his scaphoid injury and July 2007 notes indicate he had some tenderness over the dorsal scaphoid, but Watson's test was stable now without significant tenderness. There was some pain with ulnar loading and his neurovascular exam was intact. The July 2007 private orthopedic note also indicated that he was still too tender to work and would be kept from working for the next six weeks. A May 2007 VA ambulatory care note indicated the Veteran had what sounded like tennis elbow which he attributed to his working situation and reported being fired yesterday of this. The Veteran was afforded an October 2007 VA knee examination and the report indicated a diagnosis of left knee chondromalacia. The Veteran reported flare-ups of knee pain one to two times a week when the knee tended to lock which lasted for a minute or two. He has had no incapacitating episodes of the knee condition. He is able to attend to his activities of daily living without assistance. He reported difficulty trying to squat; he does not kneel; he could not cross his legs; he has shooting pains that goes down his leg when he is going down steps; he is able to sit fairly comfortably with his leg outstretched; and he could walk at least a block, but less than a mile. He reported that his occupation is a full-time student and he indicated that he has not missed any of his classes secondary to the knee condition. A December 2009 VA wrist examination report indicated that the Veteran was currently working at a VA suicide prevention hotline. The examiner indicates that the Veteran was currently working and his work loss had been minimal. The Veteran stated that prior to his present job he lost two previous positions because he was unable to carry out the work that was necessary for those jobs. In addition, the Veteran has had chronic ankle sprains for which he has had arthroscopies of both ankles. His functional limitations are fairly severe with regard to the right wrist. He is not able to do any lifting, pushing, or pulling with the right upper extremity. He has difficulty traveling in a car with difficulty steering the automobile. He has difficulty sleeping due to the discomfort in his wrist and he has difficulty with writing. In a June 2012 VA medical opinion, the examiner indicated that the Veteran's peripheral nerve condition impacted his ability to work described as because of his service-connected wrist condition he left a manual job in 2006 and he now had a new job predominately desk work and he continued to have limitations with physical labor including grip, grab, pushing, and lifting with his right wrist. A February 2014 VA amputations disability benefits questionnaire (DBQ) report indicated the Veteran was service-connected for amputation of the right middle fingertip and the condition did not impact the Veteran's ability to work. A February 2014 VA back DBQ indicated report indicated the Veteran's back condition impacted his ability to work described as lifting limited to 50 pounds. A February 2014 VA knee DBQ indicated report indicated the Veteran's knee condition impacted his ability to work described as walking/standing was limited to 15 minutes and then a break. A February 2014 VA wrist DBQ indicated report indicated the Veteran's wrist condition impacted his ability to work described as no use of the right hand. A February 2014 VA peripheral nerves DBQ indicated report indicated the Veteran's peripheral nerves condition did not impacted his ability to work. A February 2014 VA hernia DBQ indicated report indicated the Veteran's peripheral hernia condition did not impacted his ability to work. In a March 2014 correspondence, the Veteran reported that he returned to school and has been able to secure other employment that allows him to sit at a desk and use his left hand for the majority of every task and answer phones. A November 2014 response to request for employment information indicated the Veteran was terminated from his employment in May 2007 as a production associate for insubordination. The Veteran was afforded an August 2016 VA wrist examination and the report indicated his wrist condition limited impacted his ability to perform any type of occupational task described as limited by being unable to open jars, unable to lift more than 25 pounds, unable to perform repetitive movements, and slow keyboarding. In September 2016 DBQ opinion, the VA examiner opined that the Veteran's only work restriction is no lifting over 50 pounds and walking/standing limitations and his service related disabilities would prevent very physical labor but not sedentary or mild physical employment The record shows that the Veteran has experienced some periods of unemployment during the period at issue. See May 2007 VA ambulatory care note; June 2012 VA examination report; and March 2014 Veteran's Application for Increased Compensation Based on Unemployability. However, the Board finds that despite experiencing some unemployment, the record shows that the Veteran was able to obtain and maintain substantial gainful employment and is currently employed. See March 2014 Correspondence and March 2014 Veteran's Application for Increased Compensation Based on Unemployability. Additionally, the Veteran has experienced absences from work. However, his absences are not the result of his service-connected disabilities. Significantly, a May 2007 private orthopedic treatment note indicates the Veteran reported wrist pain after he suffered a fall at work and July 2007 private orthopedic note also indicated that he was still too tender to work and would be kept from working for the next six weeks. Moreover, the Board notes the periods of unemployment are not the result of his service-connected disabilities. The term unemployability is not synonymous with the terms unemployed and unemployable for the purposes of determining entitlement to TDIU. A Veteran may be unemployed or unemployable for a variety of reasons, but a determination as to entitlement to TDIU is appropriate only when a Veteran's unemployability is the result of a service-connected disability. See M21-MR, Part IV, Subpart ii, Chapter 2(F)(24)(c). Significantly, while the Veteran has reported that he became too disabled to work as of May 2007 due to his service-connected disability, a November 2014 response to request for employment information indicated the Veteran was terminated from his employment in May 2007 as a production associate for insubordination. Further, the record reveals that the Veteran is currently employed. The Board acknowledges his service-connected disabilities have resulted in limitations; however these do not preclude his ability to obtain and maintain substantially gainful employment. See September 2005,October 2007, December 2007, June 2012, February 2014, March 2014; September 2016, and May 2017 VA examination reports. Moreover, the evidence shows the Veteran is maintaining his job at this time. In light of the above, the Board finds that the preponderance of the evidence shows that the Veteran is currently maintaining substantial gainful employment (with some difficulties) in a job that allows for him to sit at a desk and use his left hand for the majority of every task and answer phones. Moreover, even if the Veteran becomes unable to perform his current job, the preponderance of the evidence indicates that the Veteran would be able to obtain and maintain substantial gainful employment of another job. Accordingly, after reviewing the evidence of record, the Board finds that a TDIU is not warranted and referral to the Director of Compensation Service for any period on appeal is also not warranted because the preponderance of the evidence is against a finding that the Veteran is unable to maintain substantial gainful employment. ORDER For the period prior to June 3, 2009, an initial disability rating of 30 percent for peripheral neuropathy, right hand is granted. For the entire period on appeal, a TDIU is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs