Citation Nr: 1829635 Decision Date: 07/11/18 Archive Date: 07/24/18 DOCKET NO. 10-22 907A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a vision disorder. 2. Entitlement to service connection for myalgia. 3. Entitlement to service connection for conjunctivitis, to include as secondary to the service-connected vasomotor rhinitis with nasal polyps. 4. Entitlement to service connection for a deviated septum. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for a cervical spine disorder. 7. Entitlement to service connection for residuals of a basilar bone fracture. 8. Entitlement to service connection for a thorax disorder 9. Entitlement to service connection for total body arthritis. 10. Entitlement to service connection for sinusitis, to include as secondary to the service-connected vasomotor rhinitis with nasal polyps. 11. Entitlement to service connection for asthma, to include as secondary to the service-connected vasomotor rhinitis with nasal polyps. 12. Entitlement to service connection for a bilateral elbow disorder. 13. Entitlement to service connection for gout. 14. Entitlement to service connection for a temporomandibular joint (TMJ) disorder. 15. Entitlement to service connection for a thoracolumbar spine disorder. 16. Entitlement to service connection for obstructive sleep apnea, to include as secondary to the service-connected vasomotor rhinitis with nasal polyps and/or posttraumatic stress disorder (PTSD). 17. Entitlement to service connection for chronic laryngitis. 18. Entitlement to service connection for body scars. 19. Entitlement to service connection for erectile dysfunction, to include as secondary to the service-connected PTSD. 20. Entitlement to service connection for a pelvis disorder. 21. Entitlement to service connection for a bilateral shoulder disorder. 22. Entitlement to service connection for a bilateral knee disorder. 23. Entitlement to service connection for a bilateral ankle disorder. 24. Entitlement to service connection for a bilateral foot disorder. 25. Entitlement to an initial rating in excess of 30 percent prior to June 27, 2014, and in excess of 70 percent prior to December 5, 2016, for PTSD with traumatic brain injury (TBI). 26. Entitlement to an initial rating in excess of 30 percent for vasomotor rhinitis with nasal polyps. 27. Entitlement to an initial rating in excess of 10 percent prior to December 5, 2016, and in excess of 40 percent thereafter, for sciatic neuritis of the left lower extremity. 28. Entitlement to an initial rating in excess of 10 percent prior to December 5, 2016, and in excess of 40 percent thereafter, for sciatic neuritis of the right lower extremity. 29. Entitlement to an initial compensable rating for fourth finger fracture of the right hand. 30. Entitlement to a total rating based on individual employability due to service-connected disabilities (TDIU) prior to June 20, 2016. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Barstow, Counsel INTRODUCTION The Veteran had active military service from September 1961 to September 1964. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2008 and November 2015 rating decisions of the VA Regional Office (RO) in Houston, Texas. In January 2018, the Veteran testified at a Travel Board hearing conducted before the undersigned. The Board observes that the issue of service connection for vertigo was noted to be on appeal and was discussed at the 2018 hearing. However, the Board observes that a December 2015 rating decision granted service connection for vertigo with tinnitus; as such, that issue is not on appeal. Additionally, a February 2017 rating decision awarded TDIU, effective the date a claim for TDIU was received in June 2016. As the Veteran has asserted that his service-connected disabilities, particularly his PTSD with TBI, render him unemployable, then as per Rice v. Shinseki, 22 Vet. App. 447 (2009) the Board considers the issue of entitlement to a TDIU prior to June 20, 2016, to be on appeal. Furthermore, the Veteran appealed the effective dates of some claims. These issues were not addressed at the Veteran's January 2018 hearing. It appears that the RO is still working on these claims, as the Veteran requested a video hearing for those issues and they have not yet been certified to the Board. Consequently, the Board concludes that the earlier effective date claims are not currently before it. Additional evidence has been added to the claims file since the last Supplemental Statement of the Case (SSOC). Here, however, some of the records are not pertinent to the issues on appeal; other records, while pertinent to the issues, are merely cumulative or duplicative of information already in the claims file and therefore, considered by the RO. Consequently, as regards the issues being decided herein, a remand is not necessary. The issues of service connection for a vision disorder, conjunctivitis, bilateral hearing loss, sinusitis, asthma, gout, TMJ disorder, obstructive sleep apnea, chronic laryngitis, erectile dysfunction, and bilateral ankle disorder; and for a higher initial rating for the fourth finger disability, being remanded are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran does not have current myalgia. 2. Resolving all doubt in the Veteran's favor, a deviated septum was incurred as a result of service. 3. The Veteran's current cervical spine disorder is not shown to be etiologically related to service. 4. The Veteran does not have current residuals of a basilar bone fracture other than those that are already service-connected. 5. The Veteran does not have a current thorax disorder. 6. The Veteran does not have total body arthritis; to the extent that arthritis is present in this case, the affected joints are separately addressed. 7. The Veteran's current bilateral elbow disorder is not shown to be etiologically related to service. 8. The Veteran's current thoracolumbar spine disorder is not shown to be etiologically related to service. 9. The Veteran's current body scars are not shown to be etiologically related to service. 10. The Veteran's does not have a current pelvis disorder. 11. The Veteran's current bilateral shoulder disorder is not shown to be etiologically related to service. 12. The Veteran's current bilateral knee disorder is not shown to be etiologically related to service. 13. The Veteran's current bilateral foot disorder is not shown to be etiologically related to service. 14. Prior to July 18, 2009, the Veteran's service-connected PTSD with TBI was productive of occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of the inability to perform occupational tasks. 15. Since July 18, 2009, the Veteran's service-connected PTSD with TBI is productive of total occupational and social impairment. 16. The Veteran's service-connected vasomotor rhinitis with nasal polyps does not result in such an exceptional disability picture that the available schedular evaluation is inadequate. 17. Throughout this appeal, the Veteran's sciatic neuritis of the left lower extremity results in moderately severe incomplete paralysis. 18. Throughout this appeal, the Veteran's sciatic neuritis of the right lower extremity results in moderately severe incomplete paralysis. 19. The Veteran's combined disability during the entire pendency of this appeal meets the criteria for schedular consideration of TDIU. 20. The Veteran completed four years of college and has not been gainfully employed since February 2005. 21. The Veteran's service-connected disabilities preclude his substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for myalgia have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for a deviated septum have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2017). 3. The criteria for service connection for a cervical spine disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2017). 4. The criteria for service connection for a basilar bone fracture have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2017). 5. The criteria for service connection for a thorax disorder have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2017). 6. The criteria for service connection for total body arthritis disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2017). 7. The criteria for service connection for a bilateral elbow disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2017). 8. The criteria for service connection for a thoracolumbar spine disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2017). 9. The criteria for service connection for body scars have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2017). 10. The criteria for service connection for a pelvis disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2017). 11. The criteria for service connection for a bilateral shoulder disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2017). 12. The criteria for service connection for a bilateral knee disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2017). 13. The criteria for service connection for a bilateral foot disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2017). 14. The criteria for an initial rating in excess of 30 percent for PTSD with TBI have not been met for the period prior to July 18, 2009. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2017). 15. The criteria for a 100 percent rating for PTSD with TBI have been met for the period beginning July 18, 2009. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2017). 16. The criteria for an initial rating in excess of 30 percent for vasomotor rhinitis with nasal polyps have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.10, 4.97, Diagnostic Code 6522 (2017). 17. The criteria for an initial rating of 40 percent, but no higher, have been met for the period prior to December 5, 2016, for sciatic neuritis of the left lower extremity. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8520 (2017). 18. The criteria for a rating in excess of 40 percent have not been met for the period beginning December 5, 2016, for sciatic neuritis of the left lower extremity. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8520 (2017). 19. The criteria for an initial rating of 40 percent, but no higher, have been met for the period prior to December 5, 2016, for sciatic neuritis of the right lower extremity. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8520 (2017). 20. The criteria for a rating in excess of 40 percent have not been met for the period beginning December 5, 2016, for sciatic neuritis of the right lower extremity. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code 8520 (2017). 21. The criteria for an award of TDIU have been met for the period prior to July 18, 2009, prior to a 100 percent schedular rating being in effect. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to notify and assist As a preliminary matter, the Board has reviewed the claims file and finds that there exist no deficiencies in VA's duties to notify and assist that would be prejudicial and require corrective action prior to a final Board determination. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159; see also Bryant v. Shinseki, 23 Vet. App. 488 (2010) (regarding the duties of a hearing officer); Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (corrective action to cure a 38 C.F.R. § 3.159(b) notice deficiency); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004) (timing of notification). II. Service connection claims A. Applicable laws and regulations Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, 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). Certain disabilities, including arthritis, are presumed to be service connected if manifested to a compensable degree within one year following service. 38 C.F.R. §§ 3.303, 3.307, 3.309. A disability may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310(a), (b). B. Myalgia The Board has reviewed the Veteran's service treatment records (STRs) and post-service medical records, but finds no evidence suggesting myalgia. To the extent that the Veteran has orthopedic problems with various joints, such are being addressed below for each individual joint claimed. A March 2008 VA orthopedic examiner provided specific diagnoses for the Veteran's cervical and lumbar spines, bilateral shoulders, right fourth finger, and bilateral knees; no general diagnosis of myalgia was provided. The examiner noted that myalgia was pain in a muscle or pain in multiple muscles. They noted that the only reference in the Veteran's STRs was to the cervical spine. The examiner opined that current cervical spine, lumbar spine, and myalgia subjective symptomatology was not caused by or the result of active duty service. They noted that examination was suboptimal; they could not perform and actually were inhibited by the Veteran to perform an expert examination because of the subjective responses, which depended entirely upon individual perception and/or veracity/volitional embellishment of the Veteran. There are no treatment records or medical opinions suggesting that the Veteran has a current diagnosis of myalgia. In considering the above evidence, the Board is cognizant of the holding of Saunders v. Wilkie, 886 F.3d. 1356 (Fed. Cir. 2018). In that decision, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that, where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. This case is distinguishable, however, insofar the 2008 examination has shown findings that are firmly inconsistent with functional impairment. The 2008 examiner's findings were based on an examination of the Veteran, his reported history, and a claims file review. The Board finds it to have greater probative value than the lay opinion of the Veteran, who lacks medical training and credentials. Put simply, there is no chronic disability process, diagnosed or otherwise, for which service-connected compensation is warranted. In light of the finding of no current disability, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107(b). C. Deviated septum In this case, the Veteran's September 1961 enlistment examination revealed a normal nose and no associated complaints. The Veteran was hit by a motor vehicle in June 1963 sustaining a head injury. A May 1964 STR shows that the Veteran had nasal septum deviation, while a post-service March 1998 record shows that the Veteran continues to have nasal septum deviation. Considering the Veteran's normal enlistment examination; in-service injury; and that a deviated septum was first diagnosed in service, after resolving all doubt in the Veteran's favor, service connection is found to be warranted for a deviated septum. This claim is thus granted in full. 38 U.S.C. § 5107(b). D. Cervical spine disorder In this case, the Board acknowledges the diagnosis of a current cervical spine disorder; complaints were first noted in April 1999 when the Veteran was reported as having neck pain for the past couple of years, and was diagnosed with cervical spondylosis. An April 2002 record shows that the Veteran reported injuring his neck at work; his reported diagnoses included degenerative disc disease. The Board has reviewed the STRs and notes that in June 1963, the Veteran was treated after he reported being beaten by a mob of German nationals and hit by their car. No cervical spine complaints were shown in the June 1963 records pertaining to that injury. An October 1963 record shows that the Veteran had a cervical history of skull fracture and continued to complain of pain in the nape of his neck; he was diagnosed with questionable myalgia. X-rays revealed that nothing abnormal was seen. There were no cervical spine complaints in his June 1964 separation examination and physical. A left-sided skull fracture with hematotympanum in June 1963 was noted; no associated cervical spine injury was reported. Given the above, the remaining question for the Board is whether there is an etiological relationship, or nexus, between the current disability and service, particularly the June 1963 injury. The Veteran described injuring his neck in the June 1963 assault and motor vehicle accident at his January 2018 hearing. Competent evidence directly addressing the question of nexus is limited to October 2006 and November 2006 private opinions, a March 2008 VA orthopedic examination report, and an August 2015 VA neck conditions examination report. The October 2006 private physician, after review of the STRs, opined that there were no other injuries to account for his early and progressive spinal degeneration. They opined that the acceleration/deceleration injuries plus ground impact on his body caused by a high velocity vehicle produced poly traumatic injuries. The private November 2006 physician opined that the Veteran's injuries from the 1963 accident included aggressive degeneration of the cervical spine. The March 2008 VA examiner, after a claims file review, opined that the Veteran's cervical spine disorder was not caused by or the result of active duty service. The August 2015 VA examiner, after a claims file review, opined that the cervical spine disorder was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The Board finds that the 2008 and 2015 VA examination opinions constitute the most probative evidence of record, as, in each case, the examiners reviewed the claims file and provided detailed rationales. With regards to the private October 2006 opinion, the physician reported seeing the Veteran in January 1965 for neck pain and that X-rays in July 1965 showed degenerative disc disease. They opined that it was "amazing" that the Veteran should have spinal degenerative disc disease at the young age of 20 unless there had been a serious injury such as the one suffered in the military in June 1963. The Board acknowledges that they reviewed the Veteran's STRs; however, they did not address the fact that the records pertaining to the accident showed no cervical spine complaints; the normal X-rays in October 1963; or the normal separation examination in 1964. The 2006 physician noted reviewing records from 1999 and the October 2006 letter. They reported that the Veteran's injuries from his 1963 accident included aggressive degeneration of the cervical spine. This physician did not have the benefit of reviewing the claims file, which did not show cervical spine complaints at the time of the 1963 accident, and which revealed a normal spine at separation from service. The 2008 examiner noted at the time of the 1963 injury, there was no involvement of the cervical spine to that condition. They reported that based on the Veteran's post-service record time line, he began having neck problems in 1997 and physical examination and surgical intervention which followed in 1999 and 2005. The examiner observed that the Veteran related that day that his problem with his neck in fact started in 1997, although he had some contention that it had some relationship, based on sedentary lifestyle, that it had something to do with the active duty service motor vehicle accident, which the record showed that "it does not." The examiner opined that based on the Veteran's record, his issues occurred post-service, at a time in his life when he was old enough to have age-related degenerative changes not associated with active duty service. The 2015 VA examiner noted that there was no complaint or diagnosis of any neck injury or problems at the time of the June 1963 injury. They noted the October 1963 record, and that the Veteran's separation examination in June 1964 did not show any complaints or diagnosis of neck chronic complaints or conditions, with normal neurologic/spine exam reported by examiner. They observed that there was no evidence of degenerative disc disease of the cervical spine in service. The examiner noted a consult from 2002 showing evidence of a neck injury while heavy lifting on the job at a trade show. They noted the October 2006 private opinion; the examiner observed that besides this letter, the private medical records since 1964 to 1975 mentioned by that physician were not available for review. The examiner also noted the November 2006 record in which the physician opined that the October 2006 opinion provider had the advantage of longitudinal follow up with the Veteran regarding his military associated injuries. The examiner reported that such seemed to be a case consult single evaluation based on medical exam, review of medical records, and the previous October 2006 statement. They noted that there were still no private medical records related to the claimed conditions prior to 1999 noted in that letter. The examiner concluded that the only initial evidence of a neck condition after service available for review in claims file was from 1999. They opined that the time gap between discharge from active duty and the evidence of the date when the diagnosis of the current claimed condition was established, plus the lack of chronic neck symptoms during active duty, the Veteran's current cervical spine disorder was less likely than not incurred in or caused by the neck pain and/or the car accident noted during service. Since the 2008 and 2015 VA examiners provided detailed rationales that discussed the pertinent service and post-service evidence of record, as compared to the private 2006 opinions, the Board accords them more probative value. As to the Veteran's own contentions, he is competent to observe lay symptoms but does not have the training or credentials to provide a competent opinion as to a diagnosis or the onset date of such diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). His lay contentions therefore lack probative value as compared to the VA examination opinions. In summary, the preponderance of the evidence is against the claim for service connection for a cervical spine disorder, and the claim must be denied. 38 U.S.C. § 5107(b). E. Basilar bone fracture In this case, in a December 2017 statement, the Veteran asserted symptoms of inhibited hair growth, a scarred and sensitive left ear, and a growth on the right ear resulting in hearing loss as residuals of a basilar bone fracture. The Board has reviewed the Veteran's STRs and notes the June 1963 injury; he was diagnosed with a skull fracture from that accident. His June 1964 separation examination and physical revealed a normal head; a left-sided skull fracture in June 1963 was noted. The Veteran is currently service-connected for PTSD with traumatic brain injury, post traumatic headaches, vertigo, scars of the left orbit and below left eye, and tinnitus resulting from the in-service head injury. Post-service medical records have not reflected any residuals from a skull fracture sustained in service other than those already service connected. They do not show a disability manifested by inhibited hair growth. The Board acknowledges the private October 2006 opinion indicating that the Veteran had a basal skull fracture from the 1963 injury, as well as the November 2006 opinion reporting that the Veteran's injury related diagnoses included basilar skull fracture with cerebrospinal fluid leak from the ear and nose. However, current diagnosed residuals from any in-service skull fracture have not been shown beyond what the Veteran is already service-connected for. To the extent that the Veteran claims scarring and hearing loss, such is addressed in the decision and remand below, respectively. Again, the Board is cognizant of the holding of Saunders. This case is distinguishable, however, insofar the Veteran's treatment records throughout this appeal have shown findings that are firmly inconsistent with functional impairment. The Board finds such records to have greater probative value than the lay opinion of the Veteran, who lacks medical training and credentials. Put simply, there is no chronic disability process other than those already service-connected residuals, diagnosed or otherwise, for which service-connected compensation is warranted. In light of the finding of no current disability, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107(b). F. Thorax disorder The Board has reviewed the Veteran's STRs and notes that the Veteran sustained a contusion to the thorax as a result of the June 1963 injury. His June 1964 separation examination and physical did not show any thorax complaints. Post-service medical records have not shown any current thorax disorder or any residuals from the in-service contusion. To the extent that the Veteran is claiming his thoracic spine, see, e.g., December 2017 statement, such will be addressed below as a thoracolumbar spine disorder. There are no treatment records or medical opinions suggesting that the Veteran has a current diagnosis of a thorax disorder. The Board is once again cognizant of the holding of Saunders. This case is distinguishable, however, insofar the Veteran's treatment records have shown findings that are firmly inconsistent with functional impairment. The Board finds that such records have greater probative value than the lay opinion of the Veteran, who lacks medical training and credentials. Put simply, there is no chronic disability process, diagnosed or otherwise, for which service-connected compensation is warranted. In light of the finding of no current disability, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107(b). G. Total body arthritis To the extent that the Veteran has arthritis in specific joints, such are addressed in this decision. The Board has reviewed the Veteran's STRs and post-service medical records, but notes no diagnosis of "total body" arthritis. The Board acknowledges the June 1963 injury; however, no total body arthritis was shown in service. His June 1964 separation examination and physical did not show any orthopedic or joint complaints. There are no treatment records or medical opinions suggesting that the Veteran has a current diagnosis of total body arthritis. The Board is cognizant of the holding of Saunders. This case is distinguishable, however, insofar that March 2008 and August 2015 VA examinations has shown findings that are firmly inconsistent with functional impairment. In this case, the 2008 and 2015 examiners provided specific diagnoses pertaining to individual joints as opposed to "total body arthritis." The examiners findings were based on an examination of the Veteran, his reported history, and a claims file review. The Board finds them to have greater probative value than the lay opinion of the Veteran, who lacks medical training and credentials. Put simply, there is no chronic disability process, diagnosed or otherwise, for which service-connected compensation is warranted. Again, to the extent that the Veteran has diagnoses pertaining to specific joints, those claims are addressed below. In light of the finding of no current disability, the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107(b). H. Bilateral elbow disorder In this case, the Board acknowledges the diagnosis of a current elbow disorder; X-rays in February 2009 showed bone spurs, and mild degenerative spurring was shown in July 2012 X-rays. As noted above, the Veteran was treated for injuries in June 1963, after he was hit by a car. No bilateral elbow complaints were shown in the June 1963 records pertaining to that injury. There is no elbow treatment at all in the Veteran's STRs and there were no elbow complaints in his June 1964 separation examination and physical. A left-sided skull fracture with hematotympanum in June 1963 was noted; no associated bilateral elbow injury was reported. Given the above, the remaining question for the Board is whether there is an etiological relationship, or nexus, between the current disability and service, particularly the June 1963 injury. The Veteran described injuring his elbows in the June 1963 assault and motor vehicle accident at his January 2018 hearing. Evidence directly addressing the question of nexus is limited to an August 2015 VA elbow and forearm conditions examination report. The VA examiner, after a claims file review, opined that it was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The Board finds that the 2015 VA examination opinion constitutes the most probative evidence of record, as the examiner reviewed the claims file and a provided a detailed rationale. The 2015 VA examiner noted that there was no complaint or diagnosis of elbow injuries or problems in service. They noted that the June 2004 separation examination did not show any complaints or diagnosis of chronic elbow condition complaints with normal physical exam reported by examiner. They observed that degenerative arthritis was shown since 2012. The examiner opined that the time gap between discharge from active duty and the evidence of the date when the diagnosis of the current claimed condition was established, plus the lack of symptoms during active duty, suggested that the Veteran's current degenerative arthritis of the elbows was less likely than not incurred in or caused by the car injury noted during service. There are no treatment records or medical opinions suggesting that the Veteran has a bilateral elbow disorder related to his military service. As to the Veteran's own contentions, he is competent to observe lay symptoms but does not have the training or credentials to provide a competent opinion as to a diagnosis or the onset date of such diagnosis. See Jandreau, 492 F.3d at 1377. Indeed, under VA regulations, arthritis is a disease that is shown by x-rays. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. His lay contentions therefore lack probative value as compared to the VA examination opinion. In summary, the preponderance of the evidence is against the claim for service connection for a bilateral elbow disorder, and the claim must be denied. 38 U.S.C. § 5107(b). I. Thoracolumbar spine disorder In this case, the Board acknowledges the diagnosis of a current thoracolumbar spine disorder; an MRI in August 2002 showed disc protrusion, while a November 2002 record shows that the Veteran incurred an injury to his low back in June 1998 at work. As discussed above, Veteran's STRs show that he was hit by a car in June 1963. No lumbar or thoracic spine complaints were shown in the June 1963 records pertaining to that injury. An October 1963 record shows that the Veteran had lumbago. There were no lumbar or thoracic spine complaints in his June 1964 separation examination and physical. A left-sided skull fracture with hematotympanum in June 1963 was noted; no associated lumbar or thoracic spine injury was reported. Given the above, the remaining question for the Board is whether there is an etiological relationship, or nexus, between the current disability and service, particularly the June 1963 injury. The Veteran described injuring his back in the June 1963 assault and motor vehicle accident at his January 2018 hearing. Evidence directly addressing the question of nexus is limited to October 2006 and November 2006 private opinions, a March 2008 VA orthopedic examination report, and an August 2015 VA back conditions examination report. The October 2006 private physician opined that there were no other injuries to account for the Veteran's early and progressive spinal degeneration. They opined that the acceleration/deceleration injuries plus ground impact on his body caused by a high velocity vehicle produced poly traumatic injuries. The private November 2006 physician opined that the Veteran's injuries from the 1963 accident included lumbar spine degenerative condition. The March 2008 VA examiner, after a claims file review, opined that the Veteran's lumbar spine disorder was not caused by or the result of active duty service. The August 2015 VA examiner, after a claims file review, opined that it was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The Board finds that the 2008 and 2015 VA examination opinions constitute the most probative evidence of record, as, in each case, the examiners reviewed the claims file and provided detailed rationales. With regard to the private October 2006 opinion, the physician reported seeing the Veteran in October 1964 for chronic lumbar pain and that X-rays showed degenerative disc changes. They opined that it was "amazing" that the Veteran should have spinal degenerative disc disease at the young age of 20 unless there had been a serious injury such as the one suffered in the military in June 1963. Although the physician reported that a review of the Veteran's service treatment records was performed, their report does not accurately reflect what the Veteran's STRs show. They reported that the Veteran had bruises to his back from the accident; such are not specifically reported in the Veteran's STRs. Moreover, the physician did not address the normal separation examination. The 2006 physician noted reviewing records from 1999 and the October 2006 letter. They reported that the Veteran's injuries from his 1963 accident included lumbar spine degenerative condition. Again, this physician did not have the benefit of reviewing the claims file, which did not show lumbar or thoracic spine complaints at the time of the 1963 accident, and revealed a normal spine at separation from service. The 2008 examiner noted that that there was no intercurrent record post-service to show treatment for his lumbar spine conditions until 1997 and that the last follow-up was in 2006. They opined that based on the Veteran's record, all of those issues occurred post-service at a time in his life when he was old enough to have age-related degenerative changes not associated with active duty service. The 2015 VA examiner noted the treatment for lumbago in October 1963. They also noted that the Veteran's separation examination in June 1964 did not show any complaints or diagnosis of back pain or chronic back conditions, with a normal neurologic/spine exam reported by examiner. They observed that there was evidence of back problems since 1998 from a worker's compensation hearing. They also noted another back injury from September 2002, with an MRI showing herniated disc. They noted the October 2006 private opinion; the examiner observed that besides this letter, the private medical records since 1964 to 1975 mentioned by that physician were not available for review. They noted that medical records related to the back condition available for review began in 1998. The examiner also noted the November 2006 record in which the physician opined that the October 2006 opinion provider had the advantage of longitudinal follow up with the Veteran regarding his military associated injuries. The examiner reported that such seemed to be a case consult single evaluation based on medical exam, review of medical records, and the previous October 2006 statement. They noted that there were still no private medical records related to the claimed back condition prior to 1998 noted in that letter. The examiner concluded that the only initial evidence of a back condition after service available for review in claims file was from 2002 related to the workman's compensation from injury at work from 1998. They opined that the time gap between discharge from active duty and the evidence of the date when the diagnosis of the current claimed condition was established, plus the lack of chronic back symptoms during active duty, suggested that the Veteran's current lumbar spine disorder was less likely than not incurred in or caused by the complaint of lumbago during service. Since the 2008 and 2015 VA examiners provided detailed rationales that discussed the pertinent service and post-service evidence of record, compared to the private 2006 opinions, the Board accords them more probative value. As to the Veteran's own contentions, he is competent to observe lay symptoms but does not have the training or credentials to provide a competent opinion as to a diagnosis or the onset date of such diagnosis. See Jandreau, 492 F.3d at 1377. His lay contentions therefore lack probative value as compared to the VA examination opinions. In summary, the preponderance of the evidence is against the claim for service connection for a thoracolumbar spine disorder, and the claim must be denied. 38 U.S.C. § 5107(b). J. Body scars In this case, the Board acknowledges that the Veteran has current body scars; he testified that the scars are from surgeries for certain orthopedic problems. For the reasons set forth in this decision, the Board is denying service connection for the affected joints. (While service connection for a bilateral ankle disorder is being remanded, the Veteran has not claimed scars of the ankles.) Without service connection being granted for those orthopedic disabilities, service connection for body scars resulting from surgeries to those joints is not warranted. As already indicated above, the Veteran is currently service connected for scars of the left orbit and below left eye resulting from the in-service head injury. In summary, the preponderance of the evidence is against the claim for service connection for body scars, and the claim must be denied. 38 U.S.C. § 5107(b). K. Pelvis disorder The Board has reviewed the Veteran's STRs and post-service medical records, but notes no diagnosis of any pelvis disorder. There are no records reflecting any treatment for any pelvic complaints. The Board acknowledges the June 1963 injury; however, no pelvic complaints was shown in service. His June 1964 separation examination and physical did not show any pelvic complaints. The Board is cognizant of the holding of Saunders. This case is distinguishable, however, insofar that the Veteran's treatment records throughout this appeal have shown findings that are firmly inconsistent with functional impairment. The Veteran's records show no pelvic complaints, let alone pain resulting in functional impairment. The Board finds them to have greater probative value than the lay opinion of the Veteran, who lacks medical training and credentials. Put simply, there is no chronic disability process, diagnosed or otherwise, for which service-connected compensation is warranted. In summary, the preponderance of the evidence is against the claim for service connection for a pelvis disorder, and the claim must be denied. 38 U.S.C. § 5107(b). L. Bilateral shoulder disorder In this case, the Board acknowledges the diagnosis of a current bilateral shoulder disorder; right shoulder impingement and arthritis was shown in August 2003, while left shoulder surgery was performed in May 2008. As discussed above, the Veteran's STRs show that he was hit by a car in June 1963. No bilateral shoulder complaints were shown in the June 1963 records pertaining to that injury. There were no bilateral shoulder complaints in his June 1964 separation examination and physical. A left-sided skull fracture with hematotympanum in June 1963 was noted; no associated bilateral shoulder injury was reported. Given the above, the remaining question for the Board is whether there is an etiological relationship, or nexus, between the current disability and service, particularly the June 1963 injury. The Veteran described injuring his shoulders in the June 1963 assault and motor vehicle accident at his January 2018 hearing. Evidence directly addressing the question of nexus is limited to a November 2006 private opinion, a March 2008 VA orthopedic examination report, and an August 2015 VA shoulder and arm conditions examination report. The November 2006 private physician opined that the Veteran's injuries from the 1963 accident included a right shoulder injury. The March 2008 VA examiner, after a claims file review, opined that the Veteran's bilateral shoulder disorder was not caused by or the result of active duty service. The August 2015 VA examiner, after a claims file review, opined that it was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The Board finds that the 2008 and 2015 VA examination opinions constitute the most probative evidence of record, as, in each case, the examiners reviewed the claims file and provided detailed rationales. With regards to the November 2006 private physician, they noted reviewing records beginning from 1999. They reported that the Veteran's injuries from his 1963 accident included a right shoulder injury. Compared to the VA examiners, this physician did not have the benefit of reviewing the claims file, which did not show bilateral shoulder complaints at the time of the 1963 accident, and revealed normal upper extremities at separation from service. The 2008 examiner noted that there were no bilateral shoulder complaints while the Veteran was on active duty. They reported that based on the Veteran's subjective history of the motor vehicle accident, and clinical records which showed exactly what the problem was secondary to the accident, there was no evidence to suggest nexus of the Veteran's current bilateral shoulder condition to active duty. They noted that reference to the Veteran's shoulder began in 2003. They opined that based on the Veteran's record, all of those issues occurred post-service at a time in his life when he was old enough to have age-related degenerative changes not associated with active duty service. The 2015 VA examiner noted the June 1963 accident and that there was no evidence of complaint or diagnosis of shoulder injuries or problems in service. They reported that the separation examination in June 1964 did not show any complaints or diagnosis of chronic shoulder condition complaints, with normal joints exam reported by examiner. They noted the 2003 records of shoulder treatment as well as the November 2006 physician's statement. The examiner opined that the time gap between discharge from active duty and the evidence of the date when the diagnosis of the current claimed condition was established, plus the lack of symptoms during active duty, suggested that the Veteran's current bilateral shoulder disorder was less likely than not incurred in or caused by the car injuring during service. Since the 2008 and 2015 VA examiners provided detailed rationales that discussed the pertinent service and post-service evidence of record, compared to the private 2006 opinion, the Board accords them more probative value. As to the Veteran's own contentions, he is competent to observe lay symptoms but does not have the training or credentials to provide a competent opinion as to a diagnosis or the onset date of such diagnosis. See Jandreau, 492 F.3d at 1377. His lay contentions therefore lack probative value as compared to the VA examination opinions. In summary, the preponderance of the evidence is against the claim for service connection for a bilateral shoulder disorder, and the claim must be denied. 38 U.S.C. § 5107(b). M. Bilateral knee disorder In this case, the Board acknowledges the diagnosis of a current bilateral knee disorder; an October 2006 physician's letter referenced right knee meniscus surgery in 1985, while a July 2009 bone scan showed findings consistent with degenerative joint disease in the left knee. As discussed above, Veteran's STRs show that he was hit by a car in June 1963. No bilateral knee complaints were shown in the June 1963 records pertaining to that injury. There were no bilateral knee complaints in his June 1964 separation examination and physical. A left-sided skull fracture with hematotympanum in June 1963 was noted; no associated bilateral knee injury was reported. Given the above, the remaining question for the Board is whether there is an etiological relationship, or nexus, between the current disability and service, particularly the June 1963 injury. The Veteran described injuring his knees in the June 1963 assault and motor vehicle accident at his January 2018 hearing. Competent evidence directly addressing the question of nexus is limited to October 2006 and November 2006 private opinions, a March 2008 VA orthopedic examination report, and an August 2015 VA knee and lower leg conditions examination report. The October 2006 private physician opined that the acceleration/deceleration injuries plus ground impact on his body caused by a high velocity vehicle produced poly traumatic injuries. The private November 2006 physician opined that the Veteran's injuries from the 1963 accident included a right knee meniscus injury. The March 2008 VA examiner, after a claims file review, opined that the Veteran's bilateral knee disorder was not caused by or the result of active duty service. The August 2015 VA examiner, after a claims file review, opined that it was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The Board finds that the 2008 and 2015 VA examination opinions constitute the most probative evidence of record, as, in each case, the examiners reviewed the claims file and provided detailed rationales. With regards to the private October 2006 opinion, the physician reported reviewing the Veteran's service treatment records and that the Veteran sustained abrasions of the left knee from the 1963 accident. They opined that the Veteran's injury related diagnoses included right knee meniscus injury progression to meniscus surgery in 1985. Although the physician reported that a review of the Veteran's service treatment records was performed, their report does not accurately reflect what the Veteran's STRs show. The Veteran's STRs pertaining to the accident do not address any knee abrasions. Moreover, the physician did not address the normal separation examination. The 2006 physician noted reviewing records from 1999 and the October 2006 letter. They reported that the Veteran's injuries from his 1963 accident included a right knee meniscus injury. However, this physician did not have the benefit of reviewing the claims file, which did not show bilateral knee complaints at the time of the 1963 accident, and revealed normal lower extremities at separation from service. The 2008 examiner noted that there were no bilateral knee complaints while the Veteran was on active duty. They reported that based on the Veteran's subjective history of the motor vehicle accident, and clinical records which showed exactly what the problem was secondary to the accident, there was no evidence to suggest nexus of the Veteran's current bilateral knee condition to active duty. They noted that the Veteran's right knee condition occurred almost 20 years after service, followed by a surgery, and that there was no reference to the left knee. They opined that based on the Veteran's record, all of those issues occurred post-service at a time in his life when he was old enough to have age-related degenerative changes not associated with active duty service. The 2015 VA examiner noted the June 1963 records and that there was no evidence of complaint or diagnosis of knee injuries or problems in service. They noted review of separation examination from June 1964 did not show any complaints or diagnosis of chronic knee condition/complaints, with normal physical exam reported by examiner. They observed that there was evidence of meniscus tear with surgery in 1982 per medical history in claim file and degenerative arthritis bilaterally since 2006. They reported reviewing the November 2006 statement. The examiner opined that the time gap between discharge from active duty and the evidence of the date when the diagnosis of the current claimed condition was established, plus the lack of symptoms during active duty, suggested that the Veteran's current bilateral knee disorder was less likely than not incurred in or caused by the car accident noted during service. Since the 2008 and 2015 VA examiners provided detailed rationales that discussed the pertinent service and post-service evidence of record, compared to the private 2006 opinions, the Board accords them more probative value. As to the Veteran's own contentions, he is competent to observe lay symptoms but does not have the training or credentials to provide a competent opinion as to a diagnosis or the onset date of such diagnosis. See Jandreau, 492 F.3d at 1377. Indeed, under VA regulations, arthritis is a disease that is shown by x-rays. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. His lay contentions therefore lack probative value as compared to the VA examination opinions. In summary, the preponderance of the evidence is against the claim for service connection for a bilateral knee disorder, and the claim must be denied. 38 U.S.C. § 5107(b). N. Bilateral foot disorder In this case, the Board acknowledges the diagnosis of a current bilateral foot disorder; foot pain with a diagnosis of pes planus was shown in January 2009, while degenerative changes were noted in September 2011. As discussed above, Veteran's STRs show that he was hit by a car in June 1963. No bilateral foot complaints were shown in the June 1963 records pertaining to that injury. A right foot contusion when a car door slammed on his foot was shown in February 1964. There were no bilateral foot complaints in his June 1964 separation examination and physical. A left-sided skull fracture with hematotympanum in June 1963 was noted; no associated bilateral foot injury was reported. Given the above, the remaining question for the Board is whether there is an etiological relationship, or nexus, between the current disability and service, particularly the June 1963 injury. The Veteran described injuring his feet in the June 1963 assault and motor vehicle accident at his January 2018 hearing. He also described an incident where a truck door got slammed on his leg contributing to his flat feet. Evidence directly addressing the question of nexus is limited to October 2006 and November 2006 private opinions, and an August 2015 VA foot conditions examination report. The October 2006 private physician opined that the acceleration/deceleration injuries plus ground impact on his body caused by a high velocity vehicle produced poly traumatic injuries. They opined that the Veteran's injury related diagnoses include contusions to the left foot. The private November 2006 physician opined that the Veteran's injuries from the 1963 accident included foot contusions. The August 2015 VA examiner, after a claims file review, opined that it was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The Board finds that the 2015 VA examination opinion constitutes the most probative evidence of record as the examiner reviewed the claims file and provided a detailed rationale. With regards to the private October 2006 opinion, they reported that a review of the Veteran's service treatment records was performed and that the Veteran had abrasions on the instep of his foot. Although the physician reported that a review of the Veteran's service treatment records was performed, their report does not accurately reflect what the Veteran's STRs show. The Veteran's STRs pertaining to the accident do not address any left foot contusions. Moreover, the physician did not address the normal separation examination. The November 2006 physician noted reviewing records from 1999 and the October 2006 letter. They reported that the Veteran's injuries from his 1963 accident included contusions of the foot. However, this physician did not have the benefit of reviewing the claims file, which did not show bilateral foot complaints at the time of the 1963 accident, and revealed normal feet at separation from service. The 2015 VA examiner noted the June 1963 accident and that there was no evidence of complaint or diagnosis of right foot injury or problems related to the head injury incident. They noted that there was no evidence of diagnosis of pes planus and/or degenerative arthritis of the right foot in service. They observed that there was evidence of diagnosis of bilateral pes planus and degenerative arthritis of the right foot per medical records since 2011. The examiner opined that even though the Veteran only had a right foot contusion in 1964, his current diagnostic findings were in both feet. The examiner opined that the time gap between discharge from active duty and the evidence of the date when the diagnosis of the current claimed condition was established, plus the lack of symptoms during active duty, suggested that the Veteran's current bilateral foot disorder was less likely than not incurred in or caused by the complaint of a car door slammed on the right foot during service. Since the 2015 VA examiner provided a detailed rationale that discussed the pertinent service and post-service evidence of record, compared to the private 2006 opinions, the Board accords it more probative value. As to the Veteran's own contentions, he is competent to observe lay symptoms but does not have the training or credentials to provide a competent opinion as to a diagnosis or the onset date of such diagnosis. See Jandreau, 492 F.3d at 1377. Indeed, under VA regulations, arthritis is a disease that is shown by x-rays. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. His lay contentions therefore lack probative value as compared to the VA examination opinions. In summary, the preponderance of the evidence is against the claim for service connection for a bilateral foot disorder, and the claim must be denied. 38 U.S.C. § 5107(b). III. Initial rating claims A. Applicable laws and regulations Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Where 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. See 38 C.F.R. § 4.7. In every instance where the rating schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. B. PTSD with TBI The Veteran is evaluated at the 30 percent rate prior to June 27, 2014, and at the 70 percent rate prior to December 5, 2016, for PTSD with TBI under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. There is evidence to suggest that a rating of 100 percent is warranted since July 18, 2009. Id. A July 18, 2009, record shows that the Veteran had paranoid delusions, poor insight and judgment, and executive function consistent with psychosis. Treatment records since then continue to show delusions; a November 2012 record reveals that the Veteran had persecutory delusions. The Veteran was provided with a VA initial PTSD examination in June 2014. The examiner diagnosed the Veteran with delusional disorder noted by history and opined that it was not possible to differentiate what symptoms were attributable to each diagnosis. The June 2014 examination, as well as a December 2016 fee-based review PTSD examination, showed symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships; impaired impulse control; and persistent delusions or hallucinations. In light of the Veteran's delusions dating back to July 2009; the similarity of symptoms in the 2014 and 2016 examinations; and the 2016 examiner's opinion that the Veteran's disability results in total occupational and social impairment, when affording the Veteran the benefit-of-the-doubt, the Board finds this evidence to be more clinically characteristic of the criteria for a 100 percent evaluation under DC 9411, and such evaluation is warranted from July 18, 2009. 38 C.F.R. § 4.7. However, the evidence of record prior to July 18, 2009, does not suggest that a 100 percent rating is warranted. The Board acknowledges that there no VA psychiatric examinations prior to 2014. The treatment records during this time period do not suggest that a rating in excess of 30 percent is warranted. An August 2008 record showed coherent and logical thought processes; no flight of ideas, loose associations or thought blocking; no hallucinations or delusions; no suicidal or homicidal ideation; and fair judgments and insight. Another August 2008 record revealed that the Veteran was well-groomed; had clear, coherent, and relevant speech; an euthymic mood; full-range, congruent to mood affect; and no delusions, hallucinations, or paranoia. A record in June 2009 revealed no delusions, suicidal ideation or homicidal ideation; normal speech; clear sensorium/concentration; and an angry/tense mood with appropriate affect. In sum, the records since the award of service connection until a delusional disorder was first shown in July 2009 do not suggest that a rating higher than the assigned 30 percent rating is warranted. To the extent that the Veteran's PTSD impacts his employability, entitlement to a TDIU is granted below. In making this determination, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). In this regard, the Board acknowledges the Veteran's testimony at his January 2018 hearing that he should be awarded separate ratings for his PTSD and TBI. VA PTSD and TBI examinations were provided to the Veteran in June 2014. The physician that conducted the TBI examination provided a medical opinion in December 2014. They opined, after a claims file review, that it was not possible to delineate which emotional/behavioral signs and symptoms were part of a co-morbid mental disorder and which represented residuals of TBI. They explained that each disorder had overlapping signs and symptoms and that to make such a determination would be mere speculation. The psychologist that performed the PTSD examination also provided a medical opinion in December 2014. They opined, after a claims file review, that the Veteran's TBI residuals and PTSD had overlapping signs and symptoms and that it was not possible, without merely speculating, to differentiate what signs and symptoms related to each diagnosis. In this case, in addition to the rating assigned under DC 9411 for the Veteran's symptomatology for both his PTSD and TBI, the Veteran is also in receipt of a separate 50 percent rating for post traumatic headaches; a 30 percent rating for vertigo; and noncompensable rating for hyposmia. As the 2014 examiners conducted examinations of the Veteran and reviewed the claims file, and provided opinions indicating that it was not possible to differentiate the Veteran's symptoms attributable to his PTSD versus his TBI residuals, the Board concludes that separate ratings are not warranted. The Board would again point out that these symptoms have been fully considered in the award of a 100 percent evaluation. C. Vasomotor rhinitis with nasal polyps The highest rating for vasomotor rhinitis is 30 percent under 38 C.F.R. § 4.97, DC 6522. Accordingly, a higher schedular rating is not warranted. The Board has considered whether there are other diagnostic codes that would provide a higher rating, but finds that none apply. The Veteran does not have bacterial rhinitis (DC 6523) or granulomatous rhinitis (6524). As such, a rating higher than 30 percent is not warranted on a schedular basis. At the January 2018 hearing, the Veteran's asserted that a higher rating on an extraschedular basis was warranted. The Board finds that referral for an extraschedular rating is not warranted. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the disability. 38 C.F.R. § 4.1. In exceptional cases where evaluations provided by the Rating Schedule are found to be inadequate, an extraschedular evaluation may be assigned that is commensurate with the Veteran's average earning capacity impairment due to the service-connected disorders. 38 C.F.R. § 3.321(b)(1). The United States Court of Appeals for Veterans Claims (Court) has provided a three-pronged test for determining whether extraschedular consideration is warranted. Thun v. Peake, 22 Vet App 111, 114 (2008), aff'd sub. nom. Thun v. Shinseki, 573 F.3d 1366 (Fed. Cir. 2009). First, as a threshold factor, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. In this regard, the Board must compare the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the Rating Schedule for that disability. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the Rating Schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular criteria are found to be inadequate to evaluate the claimant's disability, the Board must determine whether the exceptional disability exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. If so, then under the third step of the inquiry the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Here, though, no such special referral or consideration is warranted since the regular schedular standards applied in this case adequately describe and provide for the Veteran's vasomotor rhinitis with nasal polyps symptoms and consequent disability level. Marked interference with employment beyond that contemplated by the schedular criteria has not been shown, as there has been no commentary from any VA examiner or other treatment provider to that effect. 38 C.F.R. § 4.1. The record does not reflect a disability picture that is so exceptional or unusual that the normal provisions of the Rating Schedule would not adequately compensate him for his service-connected disability. Ordinarily, the VA Rating Schedule will apply unless there are exceptional or unusual factors that would render application of this schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). As such, special referral for extraschedular consideration is not warranted in this instance. See also Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). D. Sciatic neuritis of the left lower extremity The Veteran is evaluated at the 10 percent rate prior to December 5, 2016, and at the 40 percent rate thereafter for sciatic neuritis of the left lower extremity under 38 C.F.R. § 4.124a, DC 8520. A 10 percent rating is available for mild incomplete paralysis of the sciatic nerve. A 20 percent rating is available for moderate incomplete paralysis, and a 40 percent rating is available for moderately severe incomplete paralysis. Even higher ratings are warranted for greater degrees of symptomatology. A note accompanying the rating criteria says, in part, that the term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. There is evidence to suggest that the rating of 40 percent is warranted throughout this appeal. Id. A VA neurological disorders examination in April 2008; a VA back conditions examination in August 2015; a fee-based peripheral nerve conditions examination in December 2016; and a January 2017 VA peripheral nerve conditions examination suggest similar impairment such that a 40 percent rating is warranted. All the examinations showed decreased reflexes; the Veteran had reflexes of 1+/5 in 2008, 2015, and 2016, and 0/5 in 2017. Decreased muscle strength has also been shown; he had strength of 4/5 for the knee,3/5 for ankle plantar flexion and ankle dorsiflexion, and 2/5 for great toe extension at the 2015 examination. Although he had muscle strength of 5/5 for the knee and 4/5 for the ankle in 2016, muscle strength was 3/5 for the knees and ankle plantar flexion in 2017 and 0/5 for ankle dorsiflexion in 2017. As with the 2015 examination showing decreased sensory examination for the lower leg/ankle and foot/toes, the 2017 examination shows the same findings, while the 2016 examination shows decreased sensation for the foot/toes. Furthermore, the 2015 examination reflects severe paresthesias and/or dysesthesias as well as severe numbness. Treatment records have shown similar impairment. For example, a May 2009 record showed muscle strength of 1/5 to digital dorsiflexion and plantar flexion and 0/5 to ankle dorsiflexion/plantar flexion and inversion/eversion. Based on the similar symptoms shown during the examinations as well as in his treatment records, when affording the Veteran the benefit-of-the-doubt, the Board finds this evidence to be more clinically characteristic of the criteria for a 40 percent evaluation under DC 8520, and such evaluation is warranted. 38 C.F.R. § 4.7. However, an even higher rating is not warranted. The next rating of 60 percent contemplates severe incomplete paralysis with marked muscular atrophy. All of the examinations failed to show muscle atrophy; likewise, the Veteran's treatment records also do not show muscle atrophy. While treatment records, such as the May 2009 record showed foot drop, other impairment of no active movement possible of muscles below the knee or flexion of knee weakened or (very rarely) lost have been shown, so the highest rating of 80 percent is not warranted. Consequently, the criteria for a 40 percent rating, but no higher, have been met for the entire pendency of this appeal. In making this determination, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, supra. E. Sciatic neuritis of the right lower extremity The Veteran's sciatic neuritis of right lower extremity is also evaluated under 38 C.F.R. § 4.124a, DC 8520 as 10 percent disabling prior to December 5, 2016, and as 40 percent disabling thereafter. The criteria were discussed above and will not be addressed again. As with the left lower extremity, there is evidence to suggest that the rating of 40 percent is warranted throughout this appeal. Id. A VA neurological disorders examination in April 2008; a VA back conditions examination in August 2015; a fee-based peripheral nerve conditions examination in December 2016; and a January 2017 peripheral nerve conditions examination suggest similar impairment such that a 40 percent rating is warranted. The findings discussed above also apply to the right lower extremity, with the exception of the Veteran having muscle strength of 2/5 for ankle plantar flexion in 2015; and absent sensation of the foot/toes in 2017. Therefore, based on the similar symptoms shown during the examinations as well as in his treatment records, when affording the Veteran the benefit-of-the-doubt, the Board finds this evidence to be more clinically characteristic of the criteria for a 40 percent evaluation under DC 8520, and such evaluation is warranted. 38 C.F.R. § 4.7. However, an even higher rating is not warranted. As with the left lower extremity, symptoms indicative of a 60 percent rating have not been shown. Similarly, while treatment records such as the May 2009 record showed foot drop, other impairment of no active movement possible of muscles below the knee or flexion of knee weakened or (very rarely) lost have not been shown, so the highest rating of 80 percent is not warranted. Consequently, the criteria for a 40 percent rating, but no higher, have been met for the entire pendency of this appeal. In making this determination, the Board notes that neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, supra. IV. TDIU For the reasons set forth above, the Board has awarded a 100 percent rating for the Veteran's PTSD with TBI from July 18, 2009. Prior to the Board's award, the Veteran was in receipt of a 100 percent rating for PTSD with TBI from December 5, 2016, and in receipt of TDIU prior to that beginning June 20, 2016. The award of a 100 percent disability rating does not render moot a claim of entitlement to a TDIU. See Bradley v. Peake, 22 Vet. App. 280 (2008). However, the Veteran has not contended that a TDIU is warranted in addition to his 100 percent rating for PTSD with TBI. Consequently, the Board will not address whether a TDIU is warranted prior to July 18, 2009, as a result of the Veteran's 100 percent rating for PTSD being awarded from that date. Total disability is considered to exist when there is any impairment that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). Total ratings are authorized for any disability or combination of disabilities for which the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4, prescribes a 100 percent evaluation. 38 C.F.R. § 3.340(a)(2). The law also provides that a total disability rating based on individual unemployability due to service-connected disability may be assigned where the veteran is rated at 60 percent or more for a single service-connected disability, or rated at 70 percent for two or more service-connected disabilities and at least one disability is rated at least at 40 percent, and when the disabled person is unable to secure or follow a substantially gainful occupation as a result of the service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). In making its determination, VA considers such factors as the extent of the service-connected disabilities, and employment and educational background. 38 C.F.R. §§ 3.321(b), 3.340, 3.341, 4.16(b), 4.19. Individual unemployability must be determined without regard to any nonservice-connected disabilities or the veteran's advancing age. 38 C.F.R. § 3.341(a); see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The fact that a veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the veteran, because of service-connected disability, is incapable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. In the current appeal, service connection has been granted for psychiatric, headache, neuritis of the bilateral lower extremities, vertigo, vasomotor rhinitis, tinnitus, scars, dermatitis, fracture of fourth finger, and hyposmia disabilities. The Veteran has met the schedular criteria for consideration under 38 C.F.R. § 4.16(a) throughout this appeal. When affording the Veteran the benefit-of-the-doubt, the evidence supports a finding that his service-connected disabilities have rendered him unemployable prior to July 18, 2009. During this appeal, the Veteran's post traumatic headaches have been rated as 50 percent disabling; as set forth above, the Veteran's sciatic neuritis disabilities of the bilateral lower extremities are now rated as 40 percent disabling for each leg. Furthermore, his PTSD with TBI is rated as 30 percent disabling prior to July 18, 2009, while his vertigo and vasomotor rhinitis are each rated as 30 percent disabling during this appeal. The Veteran's June 2016 VA Form 21-8940, "Veterans Application for Increased Compensation Based on Unemployability" shows that he completed four years of college and had a master's degree. He reported that he last worked in marketing in 2005. Examinations and treatment records throughout this appeal have not shown that the Veteran has had substantially gainful employment. In this case, considering the severity of the Veteran's service-connected disabilities, as evidenced by the ratings assigned to his PTSD with TBI, post traumatic headaches, neuritis of the bilateral lower extremities, vertigo, and vasomotor rhinitis, and in light of the Veteran having not been employed during this appeal, the Board concludes that the combined effect of the Veteran's disabilities have rendered him unemployable. Consequently, the Board concludes that a TDIU prior to July 18, 2009, is warranted. In light of the above, the claim is thus granted. 38 U.S.C. § 5107(b). ORDER Entitlement to service connection for myalgia is denied. Entitlement to service connection for a deviated septum is granted. Entitlement to service connection for a cervical spine disorder is denied. Entitlement to service connection for residuals of a basilar bone fracture is denied. Entitlement to service connection for a thorax disorder is denied. Entitlement to service connection for total body arthritis is denied. Entitlement to service connection for a bilateral elbow disorder is denied. Entitlement to service connection for a thoracolumbar spine disorder is denied. Entitlement to service connection for body scars is denied. Entitlement to service connection for a pelvis disorder is denied. Entitlement to service connection for a bilateral shoulder disorder is denied. Entitlement to service connection for a bilateral knee disorder is denied. Entitlement to service connection for a bilateral foot disorder is denied. Prior to July 18, 2009, entitlement to an initial rating in excess of 30 percent for PTSD with traumatic brain injury is denied. From July 18, 2009, entitlement to a 100 percent rating for PTSD with traumatic brain injury is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial rating in excess of 30 percent for vasomotor rhinitis with nasal polyps is denied. Entitlement to an initial rating 40 percent for sciatic neuritis of the left lower extremity for the period prior to December 5, 2016, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial rating in excess of 40 percent for sciatic neuritis of the left lower extremity is denied for the period beginning December 5, 2016. Entitlement to an initial rating in 40 percent for sciatic neuritis of the right lower extremity for the period prior to December 5, 2016, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial rating in excess of 40 percent for sciatic neuritis of the right lower extremity is denied for the period beginning December 5, 2016. Entitlement to TDIU for the entire period prior to July 18, 2009, is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND After reviewing the evidence, the Board concludes that examinations are necessary for the issues of service connection for a vision disorder, conjunctivitis, asthma, sinusitis, obstructive sleep apnea, chronic laryngitis, bilateral hearing loss, erectile dysfunction, gout, TMJ disorder, and bilateral ankle disorder as either the Veteran has not been provided examinations and such are warranted under McLendon v. Nicholson, 20 Vet. App. 79 (2006), or prior examinations are not adequate. As for the fourth finger fracture of the right hand initial rating claim, the Veteran was provided a VA examination in March 2008, and such does not comply with the specifications of Correia v. McDonald, 28 Vet. App. 158 (2016). Accordingly, the case is REMANDED for the following action: 1. Furnish the Veteran a 38 C.F.R. § 3.159(b) notice letter addressing his 12 remanded claims under 38 C.F.R. § 3.310 (secondary service connection). In accordance with the provisions of 38 C.F.R. § 3.159(c)(1), make efforts to obtain all records identified by the Veteran. 2. Accord the Veteran a VA eye conditions examination, with a medical professional of appropriate expertise who has reviewed the claims file, to determine the nature and etiology of any diagnosed vision disorder and conjunctivitis. The examiner is requested to review the record and offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that any vision disorder and conjunctivitis had their onset in service or are related to the Veteran's military service. The examiner should consider the head injury incurred in June 1963. All opinions must be supported by a detailed rationale. For the Veteran's conjunctivitis, the examiner should also offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that the conjunctivitis is caused or aggravated by the service-connected vasomotor rhinitis with nasal polyps. If conjunctivitis is found to have been aggravated by the service-connected vasomotor rhinitis with nasal polyps, the examiner should quantify the approximate degree of aggravation. All opinions must be supported by a detailed rationale. 3. Accord the Veteran a VA medical examination, with a medical professional of appropriate expertise who has reviewed the claims file, to determine the nature, extent, and etiology of any diagnosed asthma, sinusitis, obstructive sleep apnea, chronic laryngitis, erectile dysfunction, gout, TMJ disorder, and bilateral ankle disorder. (Multiple examinations may instead be conducted; the Board leaves this to the discretion of the AOJ and the facility at which any examination is to be conducted.) The examiner is requested to review the record and offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that any diagnosed asthma, sinusitis, obstructive sleep apnea, chronic laryngitis, erectile dysfunction, gout, TMJ disorder, and bilateral ankle disorder had their onset in service or are related to the Veteran's military service. All opinions must be supported by a detailed rationale. For the Veteran's claimed asthma, chronic laryngitis, sinusitis, and obstructive sleep apnea, the examiner should also offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that such disorders are caused or aggravated by the service-connected vasomotor rhinitis with nasal polyps. If any of these disorders is found to have been aggravated by the service-connected vasomotor rhinitis with nasal polyps, the examiner should quantify the approximate degree of aggravation. All opinions must be supported by a detailed rationale. For the Veteran's erectile dysfunction, the examiner should also offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that the erectile dysfunction is caused or aggravated by the service-connected PTSD. If the erectile dysfunction is found to have been aggravated by the service-connected PTSD, the examiner should quantify the approximate degree of aggravation. All opinions must be supported by a detailed rationale. 4. Accord the Veteran a VA audiological examination, with a medical professional of appropriate expertise who has reviewed the claims file, to determine the nature, extent, and etiology of any diagnosed bilateral hearing loss. The examiner is requested to review the record and offer an opinion as to whether it is at least as likely as not (i.e., probability of approximately 50 percent) that any diagnosed bilateral hearing loss had its onset in service or is related to the Veteran's military service. The examiner should consider the documented left ear conductive hearing loss following the June 1963 head injury. All opinions must be supported by a detailed rationale. 5. Afford the Veteran a VA orthopedic examination with an appropriate examiner who has reviewed the claims file in conjunction with the examination to determine the current severity of the right fourth finger disability. The most current Disability Benefits Questionnaire must be employed, and all relevant findings indicated in that questionnaire must be addressed. All opinions must be supported by a detailed rationale. The examiner should address range of motion, painful motion (and at what point it starts), additional loss of motion after repetitions, and functional loss due to pain. This information must be derived from joint testing for pain on both active and passive motion, in weight-bearing, and nonweight-bearing. The examiner should also indicate the presence of ankylosis. The examination report must confirm that all such testing has been made and reflect those testing results. 6. After the completion of the instructions of paragraphs 1 through 5 and any other development deemed necessary, furnish the Veteran and his representative with a Supplemental Statement of the Case and give him an opportunity to respond before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on these matters. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ A.C. MACKENZIE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs