Citation Nr: 20002032 Decision Date: 01/09/20 Archive Date: 01/09/20 DOCKET NO. 12-11 131 DATE: January 9, 2020 ORDER Entitlement to a rating in excess of 10 percent for bilateral pes planus, prior to August 21, 2012, is denied. Entitlement to a rating in excess of 30 percent for bilateral pes planus, from August 21, 2012, is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. Prior to August 21, 2012, the Veteran’s bilateral pes planus was shown to be manifested by no more than moderate disability with mild pronation, pain on manipulation, and characteristic callosities. 2. From August 21, 2012, the Veteran’s bilateral pes planus was, at worst, shown to be manifested by objective evidence of marked deformity, pain on use accentuated, and characteristic callosities. 3. The Veteran does not meet the minimum threshold requirements for a TDIU on a schedular basis; his service-connected disabilities alone are not sufficient to preclude all forms of substantially gainful employment consistent with his education and occupational background at any time during the pendency of this claim. CONCLUSIONS OF LAW 1. Prior to August 21, 2012, the criteria for a rating in excess of 10 percent for bilateral pes planus have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.14, 4.71a, Diagnostic Code 5276. 2. From August 21, 2012, the criteria for a rating in excess of 30 percent for bilateral pes planus have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1-4.14, 4.71a, Diagnostic Code 5276. 3. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1970 to July 1972. These matters are before the Board of Veterans’ Appeals (Board) on appeal from an August 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2013, an informal conference was held between the decision review officer and the Veteran’s then representative. In February 2015, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. In January 2016 and May 2018, the Board remanded the issues for further development. Entitlement to a rating in excess of 10 percent for bilateral pes planus, prior to August 21, 2012. Entitlement to a rating in excess of 30 percent for bilateral pes planus, from August 21, 2012. Under Code 5276, a 10 percent evaluation for bilateral pes planus is assigned when there are moderate flatfeet with weight-bearing line over or medial to the great toe, inward bowing of the tendo achilles, pain on manipulation and use of the feet, bilateral or unilateral. A 30 percent evaluation is assigned for severe bilateral pes planus; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. A 50 percent rating, the maximum, is assigned when there is evidence of pronounced; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of tendo achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a. In a November 2012 rating decision, the Veteran’s 10 percent rating for his bilateral pes planus was increased to 30 percent, effective August 21, 2012. The effective date corresponds to an August 2012 VA examination. The Veteran claims the current ratings do not accurately reflect his condition during those time periods. Factual Background The Veteran was provided a VA examination for his feet in May 2010. See May 2010 VA Examination. During the examination, the Veteran reported that he felt much better with special MBT rocker bottom shoes and osteopathic manipulative treatment (OMT) and was not as crippled by pain as before. He indicated that he had previously been given special shoes and inserts that did not work well. He reported that since then, the only times he had pain was when he was barefoot for 15 to 20 minutes or when he was getting out of bed for the first time. He indicated he had stiffening feet pains until he got his shoes on and that when standing without his current special shoes, he would have pain up the spine, then the shoulder, and then the front of the body. The Veteran also reported changing his diet so he could handle the pain more often. On examination, in both feet, the May 2010 VA examiner noted there was evidence of painful motion, tenderness, and abnormal weight-bearing. The examiner noted that with active and passive motion testing without his shoes, the Veteran had adamant subjective aches and pains in the feet but changed with distraction. The examiner noted there was tenderness along the arch and plantar fascia, and that there was evidence of callosities and unusual shoe wear pattern. The examiner noted there was inward bowing on nonweight-bearing and weight-bearing that was correctable with manipulation. There was pain noted on manipulation. There was no forefoot or midfoot malalignment. There was mild pronation with arch present on nonweight-bearing but no arch on weight-bearing. Left heel valgus was less than 10 degrees but was correctable on manipulation. Weight-bearing line was medial to great toe and there was no muscle atrophy of the foot. The examiner noted the Veteran had a very high sense of symptom magnification and with distraction, the symptoms changed dramatically. After examination, the examiner determined the Veteran’s bilateral pes planus was mild in severity, and correctable with simple manipulation. VA treatment records from 2011 to 2012 noted the Veteran’s chronic foot pain and prescribed MBT shoes that helped his foot pain. See August 2012 CAPRI. A March 2012 VA treatment record noted that in his new shoes, his legs felt stronger and he had no pain. See id. An April 2012 private treatment record noted the Veteran’s continued feet pain. See May 2013 Medical Treatment Record – Non-Government Facility. The Veteran reported that he was unable to get the rocker bottom shoes and was given an Apex shoe, which was not rocker bottom. He stated that his orthotist wanted him to get braces because his tendons had died and since his orthotics were not helping, he needed braces. He reported that he had been going to PT to help with his stability and that he had fallen several times since he got the Apex shoes. On objective examination, the provider noted that range of motion of the midtarsal joints and MTPJs were pain free and within normal limits bilaterally. There were no gross bony deformities noted. The provider noted that there was negative anterior drawer test and negative talar tilt. The posterior tibia, anterior tibial, peroneal tendons, and Achilles’ were noted as intact and with no pain. There was no longer pain on the left lateral malleolus. There was pain and dysfunction noted of the posterior tibial tendon bilaterally. There was no pain to palpation over the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. There was no pain at the base of the 5th left metatarsal. An August 2012 private treatment record noted the Veteran’s reports that his new shoes helped correct a lot of his posture problems and that his pain was much improved. See August 2015 Medical Treatment Record – Non-Government Facility. The Veteran was provided another VA examination for his feet in August 2012. See August 2012 VA Examination. During the examination, the Veteran reported having pain and burning in his feet, felt that he could not lift his feet when he walked, and that he loses his balance and falls. He stated that his legs lock up from his feet and hips and that he lost strength. He described weakness in his hip flexors. He reported pain in his posterior plantar facia and described pain in his peroneal tendons. He reported feeling weakness across the top of the right foot, with pressure on the heel, and numbness and tingling across the top of the toes, specifically the metatarsals. He stated that his hips, shoulders, and back lock up, so he had to be careful on how he positioned himself in order to avoid this. The Veteran stated that he had back pain and shoulder pain which resolved with custom orthotics made by his local podiatrist. The August 2012 VA examiner noted the Veteran described multiple symptoms of his legs that sounded radicular or neuropathic but were unrelated from a patho-physiologic standpoint. The examiner noted the Veteran had not had any neurologic evaluation and per his treatment records, in multiple notes, there was a history complicated by unspecified, untreated, florid delusional and/or paranoid state. The Veteran stated that he had an irregular shoe sole wear with increased wear at the right toe secondary to frequent stubbing due to loss of power in the anterior tibia. He described doing strengthening exercises for the anterior tibia and doing reps of “up to 1200 at a time.” The Veteran described having to change his socks three to four times a day to avoid foot moisture and because he felt he had a sensitivity to polyester, which he stated his special (diabetic) socks were made of. He described crawling skin over his whole body if his feet were permitted to have any moisture on them for any length of time. On physical examination, the August 2012 VA examiner noted the Veteran had pain on use of the feet, but pain was not accentuated on use. There was no pain on manipulation of the feet and no indication of swelling on use noted. The examiner noted that there were characteristic calluses of both feet and that the Veteran’s symptoms were relieved by arch supports or built up shoes or orthotics. There was no extreme tenderness of plantar surfaces of both feet noted. The Veteran had decreased longitudinal arch height with marked deformity and marked pronation of both feet. However, the marked pronation was improved by orthopedic shoes or appliances. The examiner noted the weight-bearing line did fall over or medial to the great toe in both feet. The Veteran had inward bowing of the Achilles’ tendon in both feet but did not have marked inward displacement and severe spasm of the Achilles’ tendon on manipulation. The examiner noted the Veteran had marked manifestations of psychiatric disease which made any interpretation of his subjective statements nearly impossible. However, the examiner noted the Veteran clearly had marked pronation of the feet and calluses. Regarding his symptoms of poor balance and right toe stubbing resulting in intermittent gait issues, the examiner found these were unrelated to his flat feet, and were more consistent with neuropathic or radicular symptoms, for which he is not service connected, and had not been diagnosed formally since it developed over the past few years. The examiner noted that if he did have any nerve condition in the bilateral feet and calves, it is not related to his pronation. In a January 2013 private treatment record, the provider noted the Veteran’s continued feet pain that were much better with rocker bottom shoes. See June 2015 Medical Treatment Record – Non-Government Facility. The provider noted that the Veteran had a bad fall and hit his head last month and was hospitalized for three weeks and it was determined he was having small muscle atrophy and central core destabilization. The Veteran stated that it was determined that there were some abnormalities in his neurological testing and that he was scheduled for further evaluation on this. The Veteran reported that he was using a walking stick to help with stability. On objective evaluation, the provider noted that the Veteran’s range of motion of the midtarsal joints and MTPJs were pain free and within normal limits bilaterally. There was pronation noted as well as tight posterior muscle groups on both lower extremities. His gait was noted as antalgic and he did not bend the left knee when he walked. There were no gross bony deformities noted. The January 2013 private provider noted that there was negative anterior drawer test and negative talar tilt. The posterior tibia, anterior tibial, peroneal tendons, and Achilles’ were noted as intact and with no pain. There was no longer pain on the left lateral malleolus. There was pain and dysfunction noted of the posterior tibial tendon bilaterally. There was no pain to palpation over the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. There was no pain at the base of the 5th left metatarsal. The provider noted the Veteran still needed the rocker bottom shoes as he had done well with these for quite some time and that he had tried several other more traditional shoes and orthotics without relief. The provider noted it was when he was using these alternatives that he had falls. The provider noted these shoes encouraged the use of secondary muscles which was an issue with the Veteran and that he needed to continue to work on stretching the gastroc and posterior muscle groups. The Veteran was provided another VA examination for his feet in June 2013. See June 2013 VA Examination. During the examination, the Veteran reported that his feet were painful, felt weak, affected balance, and caused his whole body to be weak and painful and rigid. The Veteran reported the bottom of his feet as well as the lateral aspect of his feet hurt and that the pain was constant. He reported his feet felt tight and did not feel like feet and this was why he claimed to lose balance. He reported wearing orthotics that helped and that his feet were numb and could not be moved prior to the use of the orthotics. He reported that aggravating factors included weight-bearing activity and was even bothered by sitting although he took the weight off them. He explained by stating that when he sat, his back felt like it was being cut in two. He reported this was alleviated by orthotics. On physical examination, the June 2013 VA examiner noted the Veteran had pain on use of the feet and that pain was accentuated on use. There was no pain on manipulation of the feet and no indication of swelling on use noted. The examiner noted that there were no characteristic calluses of both feet and that the Veteran’s symptoms were relieved by arch supports or built up shoes or orthotics. There was no extreme tenderness of plantar surfaces of both feet noted. The Veteran had decreased longitudinal arch height with no marked deformity and no marked pronation in both feet. The examiner noted the weight-bearing line did not fall over or medial to the great toe in both feet. The Veteran did not have inward bowing of the Achilles’ tendon in both feet and did not have marked inward displacement and severe spasm of the Achilles’ tendon on manipulation. The examiner noted the Veteran’s constant use of a cane. The examiner noted there was normal strength of feet and circulation with no pedal edema. The examiner also noted the Veteran still had arch with weight-bearing and the Veteran’s pes planus was mild to moderate on the right and moderate on the left. There was very slight callous along the lateral great toes, but the rest of the feet were clear. The feet were noted as pink and warm with good capillary refill and pulses. The examiner found that the unsteady gait would not be due to his mild to moderate pes planus. A December 2013 VA treatment record noted the Veteran’s difficulty ambulating secondary to swollen and painful feet. See December 2013 CAPRI. A September 2014 private treatment record noted the Veteran’s reports of increased pain in his lower back and tightness in his lower extremities. See June 2015 Medical Treatment Record – Non-Government Facility. He reported he thought the feet may have contributed some to his current problems, but that his motor vehicle accident in August 2014 severely aggravated his pain and decreased his ability to walk. A May 2015 private treatment record noted the Veteran’s recurrent falls and abnormal gait. See January 2018 Medical Treatment Record – Non-Government Facility. The Veteran reported that since a car accident last year, he was wheelchair bound and was in rehab and that it had been nearly a year and he had not recovered. He indicated that he felt his leg tone was increased. The provider noted the Veteran’s paranoid schizophrenia made history taking a difficult task. The provider noted that his progressive lower extremity weakness was documented in prior neurology and other notes, but it appeared since August last year that his gait had progressively worsened. The provider noted that paranoid schizophrenia probably led to delayed care provision. A December 2015 private treatment record noted the Veteran’s report that he could walk until the time of his automobile accident in 2014 and that prior to that he had started to have some trouble walking. See id. The provider noted the Veteran’s reports that he started falling with walking after he was exposed to black mold and that the Veteran believed it was the black mold that caused his all over muscle weakness. The provider noted there has been no found cause or diagnosis for progressive muscle weakness. A February 2016 private treatment record noted that for the last two to three years, the Veteran had gradually worsened. See id. The provider noted the Veteran had been having difficulty walking and was now wheelchair bound and unable to transfer himself without any help. Electrodiagnostic study that had been done was negative. A January 2017 private treatment record noted the Veteran had pain in his left foot that was present only when someone pressed hard on it. See November 2018 Medical Treatment Record – Non-Government Facility. A July 2017 private treatment record noted the Veteran had pain in his foot when someone touched a particular spot and that he was nonweight-bearing. See June 2018 Medical Treatment Record – Non-Government Facility. A June 2018 private treatment record noted the Veteran was diagnosed with chronically evolving spinocerebellar syndrome, likely a genetic cause. See November 2018 Medical Treatment Record – Non-Government Facility. In an April 2019 VA examination, the examiner noted the Veteran had been in a nursing home following an accident for the past five years and that the Veteran was wheelchair bound due to multiple conditions not service connected, to include quadriplegia. See April 2019 C&P Exam. The Veteran was noted as unable to walk and was dependent of daily living activities. The examiner noted that during VA examination, there was objective evidence of spasticity and rigidity in both lower extremities that interfered with the tests required for the feet examination. However, the examiner noted that physical evaluation was performed and there was no objective evidence of inward rolling of ankle, no pain to palpation or swelling in the bilateral feet. There was no object evidence of bilateral flat feet and mild grade of deformities in both feet. There was no evidence of calluses and no contracture was noted. The Veteran reported pain sensation associated with tingling in the lower extremities to include feet caused by damage to the nerve fibers in the spinal cord due to his quadriplegia non service connected condition. On physical examination, the April 2019 VA examiner noted there was no pain on use or manipulation of the feet, no indication of swelling on use, no characteristic callouses, no extreme tenderness of plantar surfaces on either foot, and no objective evidence of marked deformity or marked pronation in either foot. The examiner noted the Veteran did not have inward bowing or marked inward displacement and severe spasm of the Achilles’ tendon in either foot. The examiner commented that she was unable to evaluate weight-bearing on evaluation since the Veteran was wheelchair bound due to quadriplegia and he could not stand up. Thus, there was no response provided as to effects of use of arch supports, built-up shoes or orthotics, whether there was decreased longitudinal arch height on weight-bearing, and whether the weight-bearing line fell over or medial to the great toe. After examination, the April 2019 VA examiner opined that the Veteran’s pes planus was less likely than not to affect other parts of his body, including tendons of the feet and his ability to ambulate. Based on careful consideration of the claims file and interview with and examination of the Veteran, the examiner found that there was no pertinent evidence in the medical records that he had been diagnosed or treated for tendons conditions to include posterior tibial tendon dysfunction (PTTD) of his feet that affected his ability to ambulate. The examiner noted that based on the medical literature, the posterior tibial tendon serves as one of the major supporting structures of the foot, helping it to function while walking. The examiner noted that PTTD is a condition caused by changes in the tendon, impairing its ability to support the arch, resulting in flattening of the foot. The April 2019 VA examiner explained that the overuse of the posterior tibial tendon is often the cause of PTTD and the symptoms may include pain, swelling, a flattening of the arch, and an inward rolling of the ankle. The symptoms usually occur after activities that involve the tendon, such as running, walking, hiking or climbing stairs. The examiner highlighted that the Veteran had been wheelchair bound for the past six years and was unable to walk inconsistent with overuse of posterior tibial tendon and that there was no tendonitis that affected his ability to ambulate. The examiner also noted that there is no pertinent evidence in the medical records reviewed and provided that the Veteran had been diagnosed with PTTD in the feet affecting his ability to ambulate prior to being wheelchair bound. The examiner found no objective evidence during the April 2019 VA examination of inward rolling of the ankle or pain to palpation or swelling in both feet consistent with PTTD in the feet that would affect his ability to ambulate. Analysis Prior to August 21, 2012 Prior to August 21, 2012, the Veteran has been assigned a 10 percent rating for his bilateral pes planus under DC 5276. The Veteran has indicated that he experienced constant foot pain. The Board notes that the Veteran is competent to give evidence about what he experiences; for example, he is competent to discuss current pain and other experienced symptoms. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). Here, however, the evidence of record establishes that the Veteran is not entitled to a rating higher than 10 percent prior to August 21, 2012. The Board acknowledges that the May 2010 VA examiner noted symptoms of pronation and callosities during examination, which are listed among the criteria for a higher 30 percent rating under DC 5276. However, there was no objective evidence of pain on manipulation and use accentuated, marked deformity, swelling or other symptoms indicative of severe pes planus. The May 2010 VA examiner had specifically determined the Veteran had “mild” pronation as opposed to a “marked” deformity of pronation. Furthermore, the examiner found after examination, that the severity of the Veteran’s pes planus was mild and symptoms were correctable with manipulation. Treatment records during this period on appeal also noted the Veteran’s bilateral foot pain was improved with MBT shoes and did not indicate severe pes planus. Instead, an April 2012 private treating provider noted that on objective examination, range of motion of the midtarsal joints and MTPJs were pain free and within normal limits bilaterally. Thus, the evidence reflects that the overall functional impairment of his pes planus was not productive of severe impairment. The Board notes the Veteran’s reports of severe foot pain. However, the Board does not find his self-reports of severe foot pain to be credible. In this regard, the May 2010 VA examiner specifically noted the Veteran had a very high sense of symptom magnification, and that with distraction, the symptoms changed dramatically. See May 2010 VA examination. The Board notes that the records are replete with references to the Veteran’s mental health and paranoid delusional component, as well as inconsistencies in the Veteran’s reporting of symptomatology. These inconsistencies and contrary findings provided by medical professionals examining the Veteran lead the Board to place less credibility on the Veteran’s statements regarding the severity of his bilateral pes planus. Therefore, the Board finds the objective evidence of record as recorded by providers who have evaluated his feet more probative and ultimately persuasive than the Veteran’s subjective reports about the severity of his pes planus, to include his level of pain. Accordingly, the Board concludes that for the period prior to August 21, 2012, the Veteran is most appropriately evaluated at the 10 percent rating under DC 5276. From August 21, 2012 From August 21, 2012, the Veteran has been assigned a 30 percent rating for his bilateral pes planus under DC 5276. The evidence of record for this period on appeal demonstrates that a rating in excess of 30 percent is not warranted for pes planus. The evidence shows that, at worst, the Veteran’s bilateral pes planus is manifested by objective evidence of marked deformity, tenderness and pain on use accentuated, and characteristic callosities, as well as subjective complaints chronic pain - i.e., symptoms that approximate “severe” pes planus under DC 5276. A 50 percent rating or greater is not warranted under DC 5276, because the evidence does not reflect that the Veteran’s disability due to bilateral pes planus reaches the level of severity to be considered a “pronounced” disability under DC 5276. See 38 C.F.R. § 4.71a. As noted, the August 2012, June 2013, and April 2019 VA examiners indicated that the Veteran did not have extreme tenderness of plantar surfaces of the feet, or marked inward displacement and severe spasm of the tendo achilles on manipulation. The Veteran also indicated his foot disability did improve with orthopedic shoes or appliances, specifically with MBT shoes. The Veteran’s pes planus has never been described as “pronounced” and there are no additional signs or symptoms that correspond to the requirements for a 50 percent rating under DC 5276. Treatment records during this period also failed to show extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achilles on manipulation. For the same reasons as discussed above, the Board finds for the period on and after August 21, 2012, the objective evidence of record as recorded by providers who have evaluated the Veteran’s feet more probative and ultimately persuasive than the Veteran’s subjective reports about the severity of his pes planus, to include his level of pain. In short, a rating greater than 30 percent for bilateral pes planus is not warranted under DC 5276 for this period on appeal. Other considerations The Board also acknowledges the Veteran’s reports of instability and resulting falls as due a tendon condition related to his bilateral pes planus throughout both periods on appeal. See November 2013 Third Party Correspondence. However, as noted above, the August 2012, June 2013, and April 2013 VA examiners and private treatment records in January 2013, December 2015, and January 2018 have indicated the Veteran’s instability and lower extremity weakness is not due to his service-connected bilateral pes planus. The Board notes that while the Veteran is competent to report experiencing and observing symptoms of instability, he has not been shown to be competent to provide a nexus opinion to relate any instability or any such tendon disorder to his service-connected bilateral pes planus. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Moreover, the Board notes the Veteran’s inconsistent statements as to the etiology of his instability. In a December 2015 private treatment record, he associated his leg weakness and instability to his exposure to mold. Regarding assertions of shoe wear causing instability, ultimately, in light of the Veteran’s inconsistent statements, the Board finds that the most probative evidence of record has not related any instability or lower extremity weakness to his pes planus. As reflected above, the Board affords decreased probative value to the Veteran’s self reports as they have been shown to be inconsistent and unsupported by the more objective medical evidence of record. The Board therefore affords little probative weight to the Veteran’s contentions and ultimately finds that the aforementioned VA examinations and treatment records as more probative than the Veteran’s lay statements. The Board also acknowledges Dr. Scholz’s assessment of bilateral posterior tibial tendonitis (PTTDS). See February 2015 Appellate Brief and June 2015 Medical Treatment Record – Non-Government Facility. However, the Board notes that the opinion was based on the subjective and inconsistent reports of the Veteran and not on a detailed review of the record. As shown throughout the record, there has been no swelling or color changes in the feet that Dr. Scholz indicated in the post service treatment records except for one report of swelling in the feet in December 2013. See June 2014 STR – Medical – Photocopy, February 2015 Appellate Brief, and March 2019 CAPRI. In contrast, the April 2019 VA examiner specifically noted a detailed review of the evidence of record and provided an extensive rationale when determining the Veteran did not have PTTD. The Board ultimately finds the April 2019 VA examiner’s conclusion that the Veteran does not have PTTD more probative and ultimately persuasive than Dr. Scholz’s opinion. The Board also finds that extraschedular consideration under 38 C.F.R. § 3.321(b)(1) has not been raised. An extraschedular rating under 38 C.F.R. § 3.321(b)(1) is based on the fact that the schedular ratings are inadequate to compensate for the average impairment of earning capacity due to the Veteran’s disability. Exceptional or unusual circumstances, such as frequent hospitalization or marked interference with employment, are required. The Board concludes that the schedular ratings are adequate to compensate the Veteran for his service-connected pes planus. 38 C.F.R. § 4.71a, DC 5276. As discussed above, the Board has concluded that the preponderance of the evidence is against a finding that any symptoms of instability are related to his pes planus. Further, as discussed above, the preponderance of the evidence is against a finding that the Veteran has foot pain to a degree not contemplated by the diagnostic criteria. Additionally, as discussed above, the preponderance of the evidence is against a finding that the Veteran has a tendon disorder related to his pes planus, to include PTTD. As such, the reports of instability, tendon disorder/PTTD, and extreme pain have not been related to his service-connected pes planus, and have not been considered in connection with his increased rating claim. Further, as discussed in more detail below in the TDIU analysis under 38 C.F.R. § 4.16(b), the Veteran’s quadriplegia is not related to, or part of, his service-connected pes planus. As the aforementioned have not been related to his pes-planus, any such functional impact caused by instability, tendon disorder, quadriplegia is not part of his pes planus. The schedular criteria have not been shown to be inadequate to rate the symptomatology attributed to his pes planus pes planus. Therefore, consideration under 38 C.F.R. § 3.321 is not raised. Entitlement to a TDIU. The Veteran contends that his service-connected disabilities prevent substantial gainful employment. VA will grant a TDIU when the evidence shows that a veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. A total rating for compensation purposes may be assigned where the scheduler rating is less than total when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more service-connected disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In this case, the Veteran’s service-connected bilateral pes planus and musculo-ligamentous strain (claimed as back condition) disabilities have not met the schedular criteria during the relevant appeal period since they only have a combined rating of 10 percent prior to August 21, 2012, and a combined rating of 40 percent from August 21, 2012. Nevertheless, even when the percentage requirements of 38 C.F.R. § 4.16(a) are not met, individual unemployability benefits may be granted on an extraschedular basis in exceptional cases when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating itself is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the Veteran had been capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training and previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Pursuant to 38 C.F.R. § 4.16(b), as noted above, when a claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), such a case shall be submitted to the Director of Compensation Services for extraschedular consideration. Here, the Board finds that remand for referral is not warranted. The record shows the Veteran reported receiving an associate degree and a bachelor’s degree and had trained to be an accountant. See January 2012 Medical Treatment Records – Furnished by SSA. His employment history provided in connection with his Social Security Administration (SSA) disability claim is detailed, and included work as an inventory clerk, as an accountant, as a janitor, as an auditor, as a distributing clerk, as an industrial truck operator, as a construction office work and project manager, as a mail clerk, and as a waiter. An April 2006 SSA disability determination noted the Veteran was found disabled as of August 2000 due to the primary diagnosis of schizophrenic, delusional (paranoid), schizoaffective, and other psychotic disorders. See January 2012 Medical Treatment Records – Furnished by SSA. The SSA disability determination found no secondary diagnosis. The May 2010, August 2012, June 2013, and April 2019 VA examiners found that the Veteran’s flat feet did not impact his ability to work despite the Veteran’s symptoms. See May 2010, August 2012, and June 2013 VA Examinations, and April 2019 C&P Exam. The May 2010 VA examiner noted the Veteran’s employment history included multiple temporary short time part time jobs. The examiner noted that a review of the treatment records revealed an untreated psychiatric condition and that the Veteran was paranoid delusional and could not seem to hold on to work, though he could work for short periods of time. The August 2012 VA examiner noted that the Veteran’s flat feet were not a cause of unemployability, although very heavy labor would be difficult for him. The examiner found that heavy labor would however be precluded anyway, secondary to his non service-connected conditions. See August 2012 VA examination. The June 2013 VA examiner noted prior examinations had indicated significant mental health issues and that the Veteran was on SSA disability presumably due to his mental health issues. See June 2013 VA examination. The examiner opined that the Veteran should be able to engage in gainful employment with regards to his feet and that his other whole body complaints are not explained by his bilateral foot condition. The examiner found there was no clinical reason for him not to be able to work based on his feet but noted the Veteran was limited to being on his feet standing and walking no more than 25 percent to 30 percent of a shift. A January 2018 VA medical opinion noted that the Veteran was unable to walk as he was wheelchair-bound and confined to a nursing home and that the Veteran’s back condition and bilateral pes planus imparted severe functional limitations. See January 2019 C&P Exam. The examiner noted the Veteran would be unable to perform even light duty or sedentary tasks. A November 2018 VA examiner noted that the Veteran’s thoracolumbar spine condition did not impact his ability to work. See November 2018 C&P Exam. A November 2018 VA medical opinion found the Veteran was able to perform sedentary work in which he could exert up to 10 pounds of force occasionally and/or negligible amount of force frequent to lift, carry, push, pull. See November 2018 C&P Exam. The opinion noted that sedentary work involved sitting most of the time, but may involve walking or standing for brief periods of time and that jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. As noted above, the April 2019 VA examiner found that the Veteran was wheelchair bound due to multiple conditions that are not service connected, to include quadriplegia. See April 2019 C&P Exam. The examiner noted the Veteran’s bilateral flat feet prevented him from physical labor but would not significantly limit his ability to work in a sedentary position with restrictions of walking and standing up for long periods without a break. The evidence indicates that prior to his non service-connected quadriplegia, his service-connected disabilities allowed for non-laborious employment. See May 2010, August 2012, and June 2013 VA Examinations, November 2018 C&P Exam, and April 2019 C&P Exam. Therefore, the Board finds that based on the evidence, jobs involving prolonged walking or standing would have likely resulted in daily exacerbations, and limited employment options that involved more strenuous activities. This would have precluded engaging in physically demanding work. In contrast, jobs that required less mobility and ambulating would be more amendable to the type of physical restrictions that resulted from his bilateral pes planus and back disabilities. Therefore, he would have likely been able to perform sedentary or administrative type work, which is an area he had previous experience. Given there is also no evidence that his service-connected disabilities prevented him from the cognitive tasks associated with employment the evidence is against finding that his service-connected disabilities prevented him from securing or following a substantially gainful occupation. Instead, the evidence of record has indicated that his non service-connected psychiatric conditions and quadriplegia prevented him from gainful occupation. See January 2012 Medical Treatment Records – Furnished by SSA, May 2010 VA examination, June 2013 VA examination, and April 2019 C&P Exam. The Board acknowledges the January 2018 VA opinion that indicated the Veteran would be unable to perform even light duty or sedentary tasks since he was unable to walk, was wheelchair bound, and was confined to a nursing home. However, as explained in detail in the April 2019 VA examination, the Veteran was wheelchair bound due to non service-connected conditions and that his quadriplegia is not service connected. Considering the April 2019 VA opinion included an extensive rationale supported by a detailed review of the evidence of record and relevant medical literature, the Board assigns more probative weight to the April 2019 VA examiner’s opinion. In contrast, the January 2018 VA opinion failed to address evidence suggesting that the Veteran was capable of sedentary work and that his lower extremity weakness and subsequent quadriplegia were not related to the Veteran’s service-connected disabilities. The January 2018 VA examiner also did not include an adequate rationale in support of his conclusory opinion. For these reasons, the January 2018 VA opinion is not entitled to much, if any, probative weight. Here, the Board assigns the April 2019 VA examiner’s opinion, in conjunction with the May 2010, August 2012, June 2013, November 2018 VA opinions, greater probative weight as they are based on examination of the Veteran and a detailed review of the Veteran’s medical history, to include the relevant period on appeal. Notwithstanding, the ultimate issue of whether a TDIU should be awarded is not a medical issue, but rather is a determination for the adjudicator. Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013) (“applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner”). After a review of the evidence of record, the Board finds that the claim for entitlement to a TDIU is not warranted when considered in association with the Veteran’s educational attainment and occupational background. In sum, the most probative evidence of record does not support his claim that his service-connected disabilities alone are sufficient to produce unemployability. Although they produce impairment to some degree, the evidence does not reflect gainful employment is precluded solely due to such service-connected disabilities. Thus, the preponderance of the evidence is against the Veteran’s claim for a TDIU. The claim for a TDIU is denied, and referral for extraschedular consideration of unemployability is not warranted. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Cheng, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.