Citation Nr: 19117118 Decision Date: 03/08/19 Archive Date: 03/08/19 DOCKET NO. 05-21 157 DATE: March 8, 2019 ORDER An increased disability rating of 40 percent for Raynaud’s like syndrome, currently is granted. An increased disability rating of 60 percent for sickle cell trait is granted. A total disability rating due to individual unemployability (TDIU) is granted, effective July 2, 2007. FINDINGS OF FACT 1. Raynaud’s-like syndrome, is manifested by characteristic attacks occurring at least daily, but not manifested by ulcers affecting the digits nor autoamputation of any digits. 2. Sickle cell trait is manifested by painful crises several times a year, without repeated painful crises occurring in skin, joints, bones or any major organs caused by hemolysis and sickling of red blood cells with anemia, thrombosis and infarction. 3. From July 2, 2007, the Veteran’s service-connected disabilities preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a 40 percent disability rating for Raynaud’s-like syndrome have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.104, Diagnostic Code 7117. 2. The criteria for a 60 percent disability rating for sickle cell trait have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.117, Diagnostic Code 7714. 3. From July 2, 2007, the criteria for a TDIU have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19, 4.25, 4.26. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from December 1990 to October 1993. Increased Ratings Service connection is in effect for Raynaud’s-like syndrome, rated 10 percent disabling, and sickle cell trait, rated 10 percent disabling. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). With regard to two issues, the appeal arises from the original assignment of disability evaluations following an award of service connection, thus the severity of the disabilities at issue are to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). With regard to the remaining issues, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). 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. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Due to the long and complicated history of this case, the Board finds that a historically summary would be of use before analyzing the merits of the above issues. In his original application for compensation in November 1998, the Veteran noted a history of cold intolerance, low body temperature, extra cold hands and feet, as well as body shivers and “the chills.” 11/17/1998 VA 21-526 Veterans Application for Compensation or Pension. In a May 2001 statement, the Veteran reported that he began to experience problems with cold weather in 1991 and stated that he could not work in cool or cold temperatures without feeling like his hands and feet were going to turn into ice cubes and falls off, even when dressed for cold weather. The Veteran stated that even in the summer, his fingers and feet often felt numb when it was cool outside. 05/16/2001 Correspondence at 5. VA treatment records indicate that the Veteran presented in September 2001 with complaints of cold intolerance and that his hands and feet felt cold, but there was no evidence of edema on physical examination. He was again seen in August 2004 with complaints of cold intolerance leading to numbness of extremities and feeling “chilled to the core.” Physical examination of the extremities demonstrated normal radial pulses bilaterally, warm/pink hands, and no digital ulcers. Assessment included “Likely Raynaud’s phenomenon.” 12/18/2004 VBMS, Medical Treatment Record- Government Facility at 9. The Veteran was again seen in June 2005 with complaints of pain in his wrists and hands as well as knees, ankles, low back and shoulders; the assessment was polyarthritis with no evidence of fracture, dislocation, or osteoarthritis or rheumatoid arthritis. 07/07/2005 VBMS, Medical Treatment Record-Government Facility at 1. In May 2006, the Veteran presented with complaints of myofascial pain syndrome. It was noted that the Veteran had been seen in rheumatology clinic in September 2005 for polyarthralgia and that work-up for inflammatory arthritis and other connective tissue disease was negative. After physical examination, he was diagnosed with fibromyalgia. 05/23/2006 VBMS, Medical Treatment Record-Government Facility. In July 2007, the Veteran presented for fibromyalgia follow-up. At that time, physical examination revealed that the joints in his hands were mildly tender to palpation at the proximal interphalangeal joint and at the wrist and elbows, right more than left. 03/17/2009 VBMS, Medical Treatment Record-Government Facility at 17. In April 2002, the Veteran underwent VA examination, at which time he reported that in cool or cold weather, his fingers became numb with decreased mobility and he developed body chills. Physical examination demonstrated that his hands and feet had normal skin, temperature and normal pulses, with normal nails and no evidence of skin changes. The Veteran was diagnosed as having cold intolerance of the hands and feet. 04/15/2002 VA Examination. He underwent a VA examination in March 2008, at which time he reported that when the temperature fell below 50-60 degrees, his whole body became cold and he got chills, including during the winter months, in the morning, and on entering air-conditioned buildings. Physical examination of the extremities revealed no swelling of either his hands or feet; both had normal range of motion, and sensation was completely intact. Examination of the skin revealed no pallor of the nail beds or skin surface, and there were no exceptional physical examination findings. 03/05/2008 VA Examination. The Veteran underwent additional VA examination in December 2010. At that time, he complained of stiff, numb, and painful joints in cold environments as well as occasional hand cramps but denied any discoloration of the fingers or toes. Physical examination demonstrated swan’s-neck deformity of the distal fourth phalanx of both hands. All joints were otherwise without redness, swelling, and deformity. Range of motion of all joints was grossly within normal limits, and the fingers and toes were cool and pink. The examiner acknowledged the previous diagnosis of polyarthralgia with an associated problem of “Raynaud’s-like syndrome.” The examiner stated, however, that the diagnosis of “Raynaud’s-like syndrome” had no clear meaning. The examiner explained that the major signs in Raynaud’s phenomenon are digital discoloration (white blanching or blue cyanosis) due to arterial vaso-constriction.in the presence of cold temperature or emotional stress. The examiner stated that as the Veteran did not have these findings, it was difficult to ascertain what was meant by “Raynaud’s-like syndrome.” The examiner noted that the Veteran clearly had cold intolerance and had reportedly experienced progressive aching of all his joints (polyarthralgia) to the point that he had been unable to work for the past three years. The examiner noted that the Veteran had had an extensive negative rheumatological work-up and did have mild recurrent hemolytic anemia versus low normal hemoglobin consistent with sickle cell trait. The examiner opined that if polyarthralgia is what is meant by “Raynaud’s-like syndrome” for purposes of service-connected disability evaluation, then the current severity was moderate to severe and had progressively increased in severity to the point of preventing him from working and preventing or limiting many normal activities of living. 12/09/2010 VA Examination. The Veteran again underwent a VA examination in January 2013. At that time, the examiner diagnosed anemia and acknowledged that the Veteran had both thalassemia and sickle cell trait which was active, requiring oral iron supplements and folic acid. He was noted to experience headaches, dyspnea on mild exertion, intermittent shortness of breath and light-headedness, easy fatigability, and weakness due to cold intolerance. The examiner noted the Veteran’s report of worsening cold intolerance, with daily “attacks” lasting one to ten hours and causing him to be unable to hold anything or use fine motor skills. 01/16/2013 VA Examination. The Veteran has also submitted multiple letters from private physicians. In an April 2002 letter, a private physician stated that the Veteran suffered damage to the circulation in his hands and feet resulting in a Raynaud’s-like condition. 05/20/2002 Medical Treatment Record-Non-Government Facility. In a November 2002 letter, the physician clarified that the Veteran suffered from intolerable frostbite conditions in his hands and feet and that even in the fall and spring, the process of handling tools had sometimes caused severe frostbite-like symptoms. 09/28/2004 VBMS, Medical Treatment Records –Furnished by SSA at 1. A February 2003 letter from a private rheumatologist indicates that the Veteran was referred to her due to excessive cold intolerance with signs of pain, paresthesia, and discoloration changes referred to as pallor and cyanosis. The rheumatologist stated that “the phenomenon was induced 2 different ways and we effectively found overall pallor in both hands and distal cyanosis in all fingers accompanied by hypersensitivity upon simple touch.” The physician opined that the Veteran was experiencing “a phenomenon with certain similarity to Raynaud phenomenon, considering the hypersensitivity and cold intolerance.” Id. at 15. A March 2003 letter from a different private physician indicates that on physical examination, the Veteran was pale, most notably so in his limbs, with cold hands and feet. In a second March 2003 letter, the physician stated that regarding the cold, the Veteran should avoid working in a cold environment. The physician noted that such measures had not been followed, and the Veteran had worsened resulting in physical deterioration when facing his fear of performing any activity where he could come into contact with cold. The physician noted that a rheumatologist had diagnosed an exaggerated hypersensitivity to cold and had discarded any collagen disease such as lupus or rheumatoid arthritis. 09/28/2004 Medical Treatment Records-Furnished by SSA at 69. In April 2004, the physician stated that the Veteran had a second blood disorder, thalassemia. Id. at 54. In a September 2004 letter the physician stated that the Veteran’s most important problem continued to be excessive cold intolerance, dizziness on physical activity, and pain in his extremities on physical exploration. The physician noted that the Veteran was a pale patient, most notably in his extremities, with cold hands and feet. Id. at 58. In later letters dated in July 2008, July 2009, and January2010, the physician stated that the Veteran experienced “persistent hemolytic anemia.” 02/01/2010, 07/10/2009, 06/19/2008 VBMS entries, Medical Treatment Record-Non-Government Facility. Also of record is a January 2004 SSA decision, in which it is noted that the Veteran stated that his sickle cell was diagnosed in 1990-1991. He reported that since then he had had difficulty getting enough oxygen into his body and had experienced circulatory damage resulting in Raynaud’s-like symptoms similar to frostbite, particularly affecting his hands and feet causing them to feel extremely numb and as though surrounded by ice cubes. The Veteran also stated that when his extremities became cold, he experienced pain and his extremities became red or yellow in color. The Veteran testified that he experienced these symptoms when exposed to temperatures below 60 degrees or even around strong air conditioning. 04/05/2010 VBMS, Medical Treatment Record-Furnished by SSA. An an August 2014 letter from a private physician, who reviewed the Veteran’s record and opined that all his complained-of symptoms are related to what he termed “sickle cell thalassemia,” a disorder resulting from a combination of sickle cell trait and thalassemia. The physician stated that the Veteran has experienced “well documented chronic anemia and episodes consistent with a sickling crisis,” including splenic sequestration and microvascular crisis due to low levels of blood oxygenation. The physician agreed with the December 2010 examiner who found the label “Raynaud’s-like syndrome” to have “no clear meaning,” reasoning instead that the Veteran’s symptomatology is instead likely all related to his sickle cell thalassemia. The physician stated that the disorder “places him at increased risk for sickling crises,” which lead to dizziness, weakness, and memory problems as well as his well-documented cold intolerance. In so finding, the physician also acknowledged the Veteran’s diagnosis of fibromyalgia but concluded that all of his symptoms-including cold intolerance, joint pain, memory problems, dizziness, abdominal pain, and loss of fine motor skills-are due not to Raynaud’s syndrome or to fibromyalgia but to sickle cell thalassemia, which has rendered him unemployable since 2007. The physician concluded that, if not ratable under criteria governing sickle cell thalassemia, the Veteran’s symptoms would “be best encompassed or treated as analogous to a fibromyalgia diagnosis.” 09/08/2014 Third Party Correspondence at 7. The Veteran, through his attorney, stated in a September 2014 letter that he believed the disability characterized by VA as “Raynaud' s-like syndrome" is actually fibromyalgia, as first diagnosed in May 2006. He stated that he wished his symptoms to be evaluated under 38 C.F.R. § 4.71(a), Diagnostic Code 5025, governing fibromyalgia. He also contended that he has been unable to work since2007 due to “sickling crises” caused by his sickle cell trait. Id. at 2. An October 2015 VA examiner stated that the Veteran reported “cold feelings deep into the body” but the examiner stated “that is not a fibromyalgia symptom.” He has 0/18 tender point responses. His widespread pain index is 5 joints (neck, both shoulders, both hands) and 4/10 pain at its worst. The examiner stated that the foregoing testing results were less than diagnostic criteria require so his pain medication is likely keeping his symptoms in good control. 10/02/2015 VBMS, C&P Exam. A November 2015 VA examination, by a hematologist and signed/co-authored by a Director, Compensation and Pension Unit, reflects diagnoses of anemia and sickle cell anemia trait with an “other” diagnosis of alpha thalassemia trait. 11/30/2015 VBMS, C&P Exam. The examiner provided a detailed opinion and explanation with regard to his sickle cell trait. The examiner noted that the Veteran complained of fatigue, generalized joint and muscle pain, and extreme, constant cold intolerance. These symptoms are not consistent with the natural history of sickle trait, of alpha-thalassemia trait or the combination of the two. The examiner opined that it is less likely than not that his symptoms of cold intolerance, muscle and joint pain and stiffness and his fatigue are related to his sickle trait, his alpha-thalassemia trait or the combination of the two. The examiner also opined that it is less likely as not that fibromyalgia is related to his sickle cell trait, his alpha-thalassemia trait or the combination of the two conditions. The examiner noted that fibromyalgia is not part of a sickle-trait picture and they could not find published literature linking fibromyalgia with either of his hematologic conditions. However, complicating and confusing matters even more, the examiner noted that “[e]stablishing the validity of the diagnosis of ‘fibromyalgia’ is beyond the scope of my expertise.” 11/24/2015 VBMS, VA Examination at 4. An April 2016 VA examination report for artery and vein conditions, reflects a diagnosis of cold intolerance (Raynaud’s-like syndrome) by a nurse practitioner. There were no findings of characteristic attacks, 2 or more digital ulcers, nor autoamputation of one or more digits. Subjective symptoms of shivering and numbness were reflected. 04/08/2016 VBMS, C&P Exam. The Veteran, through his attorney, asserts that treatment providers have come to an agreement that a diagnosis of fibromyalgia is most appropriate and the symptoms characterized as Raynaud’s-like syndrome are among those now being attributed to fibromyalgia. 09/12/2017 VBMS, Correspondence. An April 2018, the Board sought an opinion whether the Veteran has fibromyalgia and whether his symptoms are attributable his Raynaud’s-like syndrome. The Board did so due to the highly conflicting and confusing competent medical and lay evidence of record and because the Board found it unclear what proper diagnosis, or diagnoses, accounted for the Veteran's well-documented symptomatology. In May 2018, a VHA examiner, a board-certified neurologist, noted that the Veteran has a long history of cold intolerance, particularly affecting the hands and feet, which has undergone extensive workup. Various diagnoses have been considered including Raynaud’s-like syndrome, fibromyalgia, and sickle cell and alpha-thalassemia trait. The examiner stated that no diagnosis had been confirmed but an extensive rheumatological workup has been negative. The specialist stated that such makes a rheumatologic diagnosis extremely unlikely. The neurologist also stated that the Veteran has had an evaluation with hematology and it was noted that the Veteran’s symptoms were not consistent with the natural history of sickle cell trait, thalassemia trait, or the combination of the two. The specialist agreed that this is the case for most typical cases of sickle cell trait, thalassemia trait, or SCA/alpha-thalassemia. However, it is known that cold environments can precipitate changes in the morphology of red blood cells in individuals with sickle cell disease and it is not out of the realm of possibility for the patient with SCA/alpha-thalassemia to experience sickling under these conditions as well. In fact, the specialist opined that is the most likely explanation for the Veteran’s symptoms. The May 2018 specialist stated that he does not believe that the Veteran has Raynaud’s-like syndrome as this is neither a diagnosis nor a recognized medical condition. The neurologist opined that it is less likely than not that the Veteran’s cold intolerance is attributable to fibromyalgia as he does not have fibromyalgia. The specialist opined that the Veteran’s cold intolerance is attributable to his SCA/alpha-thalassemia condition. The specialist stated that it is important to note that sickle cell trait/thalassemia trait, and therefore the combination of SCA/alpha-thalassemia are genetic (inborn) conditions. Therefore, regardless of the date of first onset claimed by the Veteran, a nexus linking the condition and the Veteran’s military service cannot be established. The neurologist opined that the Veteran’s cold intolerance is attributable to his SCA/alpha-thalassemia condition. In June 2018, the Board sought an addendum opinion in light of the fact that service connection had been established for Raynaud’s-like syndrome, and clarification was sought as to whether his cold intolerance is attributable to or a manifestation of his Raynaud’s-like syndrome. The Board also sought clarification whether his cold intolerance is attributable to or a manifestation of his sick cell trait. Finally, the Board needed clarification whether the Veteran’s cold intolerance is attributable or a manifestation of a disability other than Raynaud’s-like syndrome or sickle cell trait. In July 2018, the same VHA specialist provided an addendum opinion. The neurologist assumed for the purpose of the addendum that the Veteran has Raynaud’s-like syndrome. The specialist stated that Raynaud’s phenomenon describes intermittent vascular constriction in areas of the body exposed to cold with accompanying two or three-phase color changes in the affected appendages. This could not explain the Veteran’s chronic cold intolerance, particularly in the context of his other significant medical history, namely his hematological condition. The specialist stated that his cold intolerance is related to his sickle cell and alpha-thalassemia trait for the reasons offered previously. Finally, the specialist stated that no other diagnoses explain the Veteran’s cold intolerance. Raynaud’s-like syndrome Raynaud’s syndrome warrants a 10 percent rating when characteristic attacks occur one to three times per week; a 20 percent rating where there are characteristic attacks occurring four to six times per week; a 40 percent rating where there are characteristic attacks occurring at least daily; a 60 percent rating with two or more digital ulcers and a history of characteristic attacks; and, a 100 percent rating with two or more digital ulcers plus autoamputation of one or more digits and a history of characteristic attacks. 38 C.F.R. § 4.104, Diagnostic Code (DC) 7117. Characteristic attacks consist of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias, and precipitated by exposure to cold or by emotional upsets. These ratings are for the disease as a whole, regardless of the number of extremities involved or whether the nose or ears are involved. 38 C.F.R. § 4.104, DC 7117, Note. As detailed, the Veteran’s Raynaud’s-like syndrome is currently rated 10 percent disabling; however, based on the medical evidence and subjective complaints of the Veteran documented in the record, the Board finds that a 40 percent rating is warranted. Such rating compensates the Veteran for symptomatology affecting the hands and feet for many years to include numbness, stiffness, pain, chills, limitation of motion, and color changes which appears to occur on a regular basis in varying weather conditions. Specifically, as detailed hereinabove, the Veteran has complained of a low body temperature, and consistently cold and numbness in the hands and feet even when dressed appropriately. The Board acknowledges that the examiners have taken issue with the Raynaud’s-like syndrome diagnosis; however, service connection has been in effect since 2001 and the Board finds that the Raynaud’s diagnostic criteria contemplates his complaints and symptomatology. The Board acknowledges that while the attacks may only occur four to six times a week, or even less at times, affording the Veteran all reasonable doubt, the Board finds that the 40 percent disability rating compensates him appropriately for his Raynaud’s symptomatology. 38 C.F.R. § 4.3. A 60 percent rating or higher is not warranted as the subjective complaints and objective findings do not show digital ulcers. Sickle cell trait The Veteran’s sickle cell trait is currently rated 10 percent disabling pursuant to 38 C.F.R. § 4.117, DC 7714. A 10 percent rating is warranted for asymptomatic sickle cell anemia, established case in remission, but with identifiable organ impairment. A 30 percent rating is warranted following repeated hemolytic sickling crises with continuing impairment of health. A 60 percent rating is warranted for painful crises several times a year or with symptoms precluding other than light manual labor. A 100 percent rating is warranted for repeated painful crises, occurring in skin, joints, bones, or any major organs caused by hemolysis and sickling of red blood cells, with anemia, thrombosis and infarction, with symptoms precluding even light manual labor. 38 C.F.R. § 4.117, DC 7714. Based on the medical evidence and subjective complaints of record, the Board finds that a 60 percent rating is warranted for symptomatology associated with his sickle cell and alpha-thalassemia trait. Specifically, as detailed, per the VHA specialist in 2018, the Veteran’s cold intolerance is due to his sickle cell and alpha-thalassemia trait and per the medical record includes symptomatology such as fatigue, generalized joint and muscle pain, and extreme cold intolerance. The Board finds that such amounts to painful crises several times a year, thus warranting a 60 percent rating. 38 C.F.R. § 4.3. A 100 percent rating is not warranted as repeated painful crises occurring in skin, joints, bones or any major organs caused by hemolysis and sickling of red blood cells with anemia, thrombosis and infarction has not been shown. Entitlement to a TDIU Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 4.16(a). If, however, there is only one such disability, it shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Disabilities of one or both upper extremities, including the bilateral factor, will be considered as one disability. 38 C.F.R. § 4.16(a)(1). Per this decision, the Veteran’s Raynaud’s-like syndrome is rated 40 percent disabling; and, his sickle cell trait is rated 60 percent disabling. His other service-connected disabilities include unspecified mood disorder rated 30 percent disabling, effective May 1, 2001; and, residuals, avulsion fracture of the right fifth digit, rated 0% disabling, effective November 16, 1998. Thus, the minimum percentage requirements for a TDIU set forth in 38 C.F.R. § 4.16(a) are met for the entire period contemplated by this appeal. The Board has determined that a TDIU is warranted effective July 2, 2007, as the evidence of record supports a finding that the Veteran has been unemployed since that time. Specifically, the Veteran was employed as an electrician from July 3, 2000 to January 3, 2002; a produce service team member from February 11, 2003 to October 28, 2005; in a maintenance capacity from December 1, 2003 to March 19, 2004; an electrical apprentice from October 4, 2004 to January 21, 2005; as a maintenance supervisor from October 2005 to April 2006. 05/04/2015 Correspondence (multiple entries). In September 2017, a private examiner opined that due to the Veteran’s symptomatology which has determined to be associated with his Raynaud’s-like phenomenon and sickle cell trait, the Veteran is unable to maintain employment as a result of these conditions and medication taken thereto. Affording the Veteran the benefit of the doubt, the Board finds evidentiary support to conclude that his service-connected disabilities preclude substantially gainful employment from July 2, 2007. His symptomatology associated with Raynaud’s-like phenomenon and sickle cell trait affect his ability to maintain gainful employment, as he is unable to consistently function in an industrial capacity with others due to his symptomology. The evidence of record establishes that the Veteran would be unable to maintain gainful employment due to the symptomatology associated with his sickle cell trait and Raynaud’s phenomenon. (Continued on the next page)   For the period prior to July 2, 2007, the evidence of record reflects that he was employed, thus there is no basis for a TDIU. Thus, for the above reasons, entitlement to a TDIU is granted from July 2, 2007, which corresponds to the date unemployability is shown. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel