Citation Nr: 20021913 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 13-11 197 DATE: March 27, 2020 ORDER Entitlement to service connection for a bilateral knee disability is granted. Entitlement to an initial rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted. Entitlement to a total disability rating based upon individual unemployability (TDIU) for the entire appeal period is granted. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to an initial rating in excess of 10 percent for a lumbar strain is remanded. Entitlement to an initial rating in excess of 30 percent for migraine headaches is remanded. FINDINGS OF FACT 1. The evidence is in equipoise as to whether the Veteran has a bilateral knee disability that is related to service. 2. For the entire appeal period, the Veteran’s PTSD manifested as occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, and mood. 3. For the entire appeal period, the Veteran’s service-connected disabilities preclude him from performing gainful employment. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran’s favor, the criteria for entitlement to service connection for a bilateral knee disability have been met. 38 U.S.C. §§ 1154(a), 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. Resolving all reasonable doubt in the Veteran’s favor, the criteria for entitlement to an initial 70 percent disability rating for PTSD have been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code (DC) 9411. 3. The criteria for the award of a TDIU for the entire appeal period has been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 2006 to January 2009, to include service in Iraq. These matters come before the Board of Veterans’ Appeals (Board) on appeal from May 2009 and April 2010 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2017, the Board remanded the matters to the RO for further development. In an August 2015 rating decision, the RO awarded a 50 percent disability rating for the Veteran’s PTSD, effective August 21, 2015, the date of the Veteran’s PTSD re-examination. The Board notes that the grant of an increased rating during the course of an appeal does not affect the pendency of that appeal. AB v. Brown, 6 Vet. App. 35 (1993). As the Veteran is presumed to be seeking the maximum allowable benefit and the maximum benefit has not yet been awarded, the claim is still in controversy and on appeal. Id. 1. Entitlement to service connection for a bilateral knee disability The Veteran contends that he is entitled to service connection for a bilateral knee disability. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurrent in service. 38 C.F.R. § 3.303(d). In order to prove service connection, there must be competent and credible evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the in- service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Turning to the evidence of record, the August 2018 VA examiner diagnosed the Veteran with a bilateral knee sprain. Additionally, a February 2018 VA treatment note reflects that the Veteran’s active medical problems include knee arthralgia. Arthralgia is “pain in a joint.” DORLAND’S ILLUSTRATED MEDICAL DICTIONARY at 1069 (31st ed. 2007). The Board notes that the United States Court of Appeals for the Federal Circuit held that pain causing functional impairment, in the absence of a present diagnosis, may still qualify as a disability for purposes of a VA service connection claim. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In this regard, the August 2018 VA knee examination reflects the Veteran has significant limitation of functional ability. Specifically, the Veteran reported pain with motion, limitation of motion, and intermittent pain with prolonged standing and walking that lasts several hours. The examiner also found that the Veteran’s bilateral knee condition resulted in disturbance of locomotion and interference with standing. Additionally, the examiner found that the Veteran’s condition impacted his ability to perform occupational tasks because of the Veteran’s physical limitations with prolonged standing and walking. The Board finds these reports of symptoms of a bilateral knee condition and the resulting functional impairment, to include occupational impairments, are sufficient to meet the current disability element of a service connection claim under Saunders, particularly when reasonable doubt is resolved in the Veteran’s favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board notes that although a disability rating is a downstream issue, painful motion also typically warrants a compensable rating. See 38 C.F.R. § 4.59. Additionally, the Veteran has reported that his bilateral knee condition is a barrier to his employment. See May 2011 VA Vocational Rehabilitation Application. As such, the Board finds the current disability element of the claim has been met both with the Veteran’s diagnosed bilateral knee sprain and documented knee arthralgia. As to the next element of service connection, review of the Veteran’s service treatment records (STRs) reflect that in a November 2008 Report of Medical Assessment, the Veteran indicated that his knees have fluid. Additionally, in the Veteran’s November 2008 separation Report of Medical History he indicated that he has knee trouble and that he is in pain sometimes. Although the Veteran’s November 2008 separation Report of Medical Examination, indicates his lower extremities are normal, the examination does not discuss the Veteran’s report of knee pain at separation. Additionally, during the October 2009 VA general medical examination, the Veteran reported that his knee pain was aggravated by training exercises during active duty and that he was treated with Ibuprofen during active duty. The Board finds that the Veteran’s reports of knee pain during service establish an in-service incurrence, injury, or disease such that the second requirement for service connection is met. Finally, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s in-service symptoms and pain are attributable to his current condition and pain. In this regard, the Veteran has competently and consistently reported experiencing bilateral knee pain since service. Indeed, the Veteran filed a service connection claim for this condition within two months of his separation from service. See March 2009 VA 21-526 Form. The Board notes that the Veteran is competent to report symptoms, including pain, which are capable of lay observation. Layno v. Brown, 6 Vet. App. 465 (1994). Further, the Board finds that the Veteran’s contentions concerning his bilateral knee disability are credible because his assertions are consistent with the other evidence of record and are not directly contracted by any evidence of record. The medical evidence of record indicates the Veteran has consistently experienced knee pain since his separation from service. In a March 2009 VA treatment record to establish care, the Veteran reported bilateral knee discomfort and pain. During the October 2009 VA general medical examination, the Veteran reported that he experienced bilateral knee pain once in a while and used nonsteroidal anti-inflammatory drugs as treatment. At the time of the examination, the examiner noted the Veteran had no limitations on standing and was able to walk more than a quarter of a mile but less than one mile. A September 2010 VA primary care note shows the Veteran’s bilateral knee range of motion decreased to 110 degrees. He was assessed with bilateral knee pain with a plan to refer him to physical therapy. Likewise, in a September 2012 VA primary care note, the Veteran was assessed with bilateral knee pain with a plan to refer him to physical therapy. August 2014, September 2014, August 2015, and September 2015 VA treatment records also all reflect knee pain. Moreover, December 2015 and April 2016 VA mental health treatment notes reflect that the Veteran’s medical history includes arthralgia of the knee. The Board is aware that the August 2018 VA examiner determined the Veteran’s bilateral knee disability is not related to service because the examiner was unable to find any medical care for a chronic recurrent bilateral knee pain or condition, including fluid in the knees. However, the Board assigns no probative value to this opinion because the examiner failed to consider the numerous reports of bilateral knee pain throughout the record as well as the VA treatment records indicating the Veteran had knee arthralgia since 2010. See February 2018 VA treatment note. Instead, the Board finds the onset of the Veteran’s knee pain, which is documented as reported by the Veteran in his separation STRs, as well as the continuous documentation of knee pain after his separation, to be a more probative source of the Veteran’s condition than the VA medical opinion of record. In consideration of the foregoing, the evidence is at least in equipoise as to whether the Veteran’s bilateral knee pain is related to service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, the Board finds that the Veteran’s disability is related to service. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, entitlement to service connection for a bilateral knee disability is warranted. 2. Entitlement to an initial rating of 70 percent, but no higher, for PTSD The Veteran contends that he is entitled to an increased rating for his service-connected PTSD. Specifically, the Veteran’s representative contends that the Veteran’s symptoms more closely approximate a 70 percent rating and, thus, the Veteran should be entitled to a 70 percent disability rating for his service-connected PTSD. See September 2016 and February 2020 Representative Briefs. By way of background, in March 2009, within one year of the Veteran’s separation from service, the Veteran filed a claim for service connection for PTSD. In an April 2010 rating decision, the RO granted service connection for PTSD and assigned a 30 percent rating, effective January 28, 2009, the day following the Veteran’s release from active duty. The Veteran timely appealed the initial rating assigned for his service-connected PTSD. Thus, the relevant period for consideration in this appeal is the entire appeal period (i.e., from January 28, 2009). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Evaluations for psychiatric disabilities are assigned pursuant to 38 C.F.R. § 4.130. The Veteran is currently rated at 30 percent from January 28, 2009 and at 50 percent from August 21, 2015 under DC 9411 for PTSD under VA’s General Rating Formula for Mental Disorders. Under the General Rating Formula for Mental Disorders, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of ability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. The Board notes that considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Further, rating evaluations under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). Although a veteran’s symptomatology is the primary consideration in assessing their disability rating based on a mental disorder, the regulation also requires an ultimate factual conclusion as to the veteran’s level of impairment in “most areas” for that rating. Id.; 38 C.F.R. § 4.130. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In the present case, after resolving reasonable doubt in the Veteran’s favor, the Board finds that the frequency, severity, and duration of the Veteran’s PTSD symptoms are equivalent to those required for a 70 percent rating. In particular, the medical evidence of record collectively indicates the Veteran’s psychiatric pathology has been productive of symptoms resulting in occupational and social impairment with deficiencies in most areas as to warrant a rating of 70 percent. In this regard, throughout the appeal period, the medical evidence of record shows that the Veteran’s PTSD has substantially impacted his social and occupational functioning. For example, in a March 2010 Social Security Administration (SSA) mental residual functional capacity assessment, a reviewing psychologist determined that the Veteran’s ability to remember and engage in complex tasks, sustain attention for extended periods, react appropriately to criticism, and adjust to changes in the workplace is limited. Additionally, in an October 2014 SSA mental residual functional capacity assessment, the reviewing psychologist noted the Veteran had problems with social interaction and found the Veteran had a markedly limited ability to complete a normal workday and workweek without interruptions from psychologically based symptoms. The psychologist found the Veteran was marginally able to adapt to the demands of an informal work environment. Likewise, in a July 2014 VA Vocational Rehabilitation and employment counseling report, the reviewing counselor determined that the Veteran’s mental health issues interfere significantly with his day to day functioning. She noted that the Veteran is hypervigilant and has difficulty trusting and working with others as well as coping with stressful situations. This evidence indicates the Veteran’s PTSD manifested in deficiencies with work such as difficulty in adapting to stressful circumstances (including work or a worklike setting) as contemplated by the 70 percent rating. Moreover, the evidence reflects that the Veteran’s PTSD manifested in social isolation. For example, in September 2015, the Veteran reported going outside only for appointments and that he liked to isolate himself from the world. See September 2015 SSA functional report. An August 2017 VA treatment note also reflects that the Veteran isolated himself in his home. Additionally, the Veteran has been hospitalized and has received in-patient PTSD and alcohol treatment throughout the appeal period. Specifically, the medical evidence of record reflects that the Veteran underwent a 28-day VA residential treatment program in 2010. See April 2016 VA treatment note. In March 2011, the Veteran also participated in VA inpatient psychiatry care at a VA medical facility in Tampa. March 2011 VA inpatient treatment notes reflect that the Veteran reported a suicide attempt approximately five months prior, for which he never sought treatment immediately after. A March 2011 VA treatment note specifically reflected that while the Veteran’s overall suicide risk appeared low, it was concerning that he did not seek medical care after his attempt and that he appeared to have fairly significant symptoms of PTSD. The Board notes that suicidal ideation is specifically contemplated in the 70 percent rating. The medical evidence also reflects that after the Veteran’s inpatient psychiatry discharge in March 2011, the Veteran resumed drinking and was subsequently arrested that same month for alcohol-related domestic violence. See April 2011 VA treatment note. The Veteran also reported hospitalization in March 2014. See March 2014 VA treatment note. The Veteran received voluntary inpatient detox care in August 2017. See October 2017 VA treatment record. In October 2017, the Veteran underwent involuntary inpatient psychiatry treatment after presenting to the emergency department with a psychiatric problem, suicidal ideation, and depression. See October 2017 Emergency Department Note. The Veteran was noncompliant with his medications and was assessed with drug intoxication. See October 2017 treatment notes. His discharge summary reflects that he denied suicidal and homicidal ideation, but his prognosis was noted as poor. The Board finds that the Veteran’s capacity for adjustment during periods of remission as well as the duration and frequency of the Veteran’s hospitalization and in-patient treatment for his PTSD symptoms reflects that the Veteran has severe and chronic functional impairments related to his disability. The medical evidence of record indicates the Veteran’s PTSD symptoms also include depression, avoidance, anger, insomnia, anxiety, suicidal ideation, paranoia, hopelessness, chronic sleep impairment, intermittent neglect of hygiene, mild memory loss, and suspiciousness. See March 2009 VA treatment record (noting that the Veteran reported avoiding relationships and easily lashing out at others); April 2010 SSA supplemental anxiety questionnaire (reflecting that the Veteran reported experiencing six anxiety attacks in the past three months and noted isolation and suicidal thoughts); October 2012 VA treatment record (noting that the Veteran reported irritability, anger, depression, sleep impairment, and that he distances himself from others); March 2014 VA treatment record (nothing the Veteran reported feelings of hopelessness, isolative behaviors, angry outbursts, and intermittent paranoia); July 2015 VA treatment note (indicating the Veteran sits around all day and cries and does not change his clothes or wash at times) and August 2015 VA PTSD examination (noting objective symptoms including suspiciousness, mild memory loss, disturbances of motivation and mood, and depressed mood). The Board finds the severity and frequency of these symptoms fit squarely within the symptomology contemplated by the 70 percent rating. The Board acknowledges that the Veteran’s PTSD symptoms do not mirror all the symptoms enumerated for a 70 percent rating under DC 9411 and that there is evidence of record reflecting more moderate symptomatology at certain periods of time during the appeal period. However, affording the Veteran the benefit of the doubt, the Board finds that such evidence is reflective of the Veteran’s waxing and waning psychiatric symptomatology and, thus, does reflect sustained improvement. Moreover, it is apparent that the Veteran’s symptoms, especially his persistent depression and anxiety; social isolation and withdrawal; suicidal ideation; chronic sleep impairment; memory problems; and anger have been of the frequency, severity, and duration to have rendered the Veteran more nearly socially and occupationally impaired with deficiencies in most areas throughout the appeal period. See Mauerhan, 16 Vet. App. at 443; Vazquez-Claudio, 713 F.3d at 117. In this regard, the Board observes that the Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing psychiatric symptoms. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Board finds that the statements provided by the Veteran on psychiatric evaluation, during the course of his treatment, and during the pendency of the claim regarding the effects of his current psychiatric symptoms on his daily life, including his occupational impairment and social isolation, are competent and credible. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). And, as indicated, these symptoms have been medically evaluated as productive of generally severe symptomatology throughout the appellate period. Thus, considering the Veteran’s competent assertions concerning his psychiatric symptoms, and resolving all reasonable doubt in the Veteran’s favor, the Board finds that, for the entire appeal period, the Veteran’s PTSD manifested in symptoms most closely approximating occupational and social impairment with deficiencies in most areas. Accordingly, a 70 percent rating is warranted for the entire appeal period. The Board notes this is a full grant of the benefits sought as the Veteran’s representative has consistently requested a 70 percent rating for the Veteran’s PTSD. See September 2016 and February 2020 Representative Briefs. Additionally, the next-higher 100 percent rating is not warranted in this case as the evidence does not indicate the Veteran had total occupational and social impairment due to such symptoms as persistent delusions or hallucinations, persistent danger of hurting self or others, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name for which a 100 percent rating is assignable. Although the Veteran expressed suicidal ideation, VA treatment providers consistently found he was not in persistent danger of hurting himself or others. Significantly, the Veteran’s VA treatment records indicate some supportive familial relationships, which does not reflect total social impairment as contemplated by the 100 percent rating. See August 2015 VA PTSD examination and April 2016 VA treatment records. 3. Entitlement to a TDIU The Veteran asserts that he is entitled to a TDIU. By way of background, in June 2010, the Veteran submitted an informal TDIU claim. See June 2010 NOD. However, a claim of entitlement to a TDIU was also raised by the record as part of the Veteran’s increased rating claims for his service-connected PTSD, lumbar strain, and migraine disabilities. See Rice v. Shinseki, 22 Vet. App. 447 (2009). VA will grant a TDIU when the evidence shows that a veteran is precluded, by reason of his service-connected disabilities, from securing and following “substantially gainful employment” consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. The central inquiry is “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). TDIU may be assigned where the schedular rating is less than total and it is found that the Veteran is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more 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 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purposes of determining rating level, disabilities resulting from a common etiology or affecting a single body system are considered a single disability. 38 C.F.R. § 4.16(a). In determining unemployability for VA purposes, consideration may be given to a veteran’s level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough, as a high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15, 4.16(a)). Medical evaluations are probative to understanding the level of functional impairment; however, the ultimate determination of unemployability is a legal question, not a medical one. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Recently, in Ray v. Wilkie, 31 Vet. App. 58 (2019), the Court defined the term “unable to secure and follow a substantially gainful occupation” in § 4.16(b) to include two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of: the Veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of doubt shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In the present case, the Veteran has met the schedular criteria for a TDIU for the entire appeal period. Specifically, the Veteran is now rated at 70 percent for his PTSD from January 28, 2009, 30 percent for his migraine headaches from January 28, 2009, and 10 percent for his lumbar strain from January 28, 2009. Although the Board is remanding the Veteran’s increased rating claims for migraine headaches and lumbar strain, the Veteran still meets the schedular criteria for a TDIU from January 28, 2009. The Veteran has also been granted service connection for a bilateral knee disability by this decision. Therefore, the threshold requirement for a TDIU rating on a schedular basis is met for the entire appeal period, and the remaining question is whether the Veteran’s service-connected disabilities prevent him from securing or following a substantially gainful occupation. After review of the evidence and resolving any doubt in the Veteran’s favor, the Board finds that the Veteran is unemployable due to his service-connected disabilities. In this regard, the Veteran reported that he had a high school education before service and has been unemployed since his discharge from service. See June 2014 VA Vocational Rehabilitation Application. The medical evidence of record also confirms that the Veteran has remained unemployed since his discharge from service. See March 2009 VA treatment record and June 2014 VA Vocational Rehabilitation Application. Additionally, the Veteran has consistently reported that his service-connected PTSD, migraines, and lumbar strain disabilities are barriers to his employment. See May 2011, August 2012, August 2013, and June 2014 VA Vocational Rehabilitation Applications. In July 2011, the Veteran was awarded SSA disability benefits with an established date of onset in February 2009. SSA found that the Veteran’s PTSD, migraines, and back disabilities were so severe that he could not perform any work existing in significant numbers in the national economy. See July 2011 SSA Notice of Decision. Specifically, SSA records note that the Veteran had been diagnosed with PTSD, which limited his ability to remember and engage in complex tasks, sustain attention for extended periods, and react appropriately to criticism or adjust to changes in the workplace. The medical documentation of record has also provided significant credibility to the Veteran’s claim that his service-connected disabilities are a major ability barrier to emplyment. For instance, in an October 2014 SSA mental residual functional capacity assessment, the reviewing psychologist found the Veteran had a markedly limited ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and that the Veteran was not able to produce concentrated effort needed to complete tasks with adequate persistence, pace, and reliability. The psychologist found the Veteran was marginally able to adapt to the demands of an informal work environment. In a July 2014 VA counseling record, a VA vocational counselor found that the Veteran’s service-connected PTSD, migraine headaches, and lumbar strain, impair his ability to prepare for, obtain, or retain employment consistent with his abilities, aptitudes, and interests. Specifically, the counselor noted the Veteran’s service-connected disabilities contribute in substantial part to his vocational impairment and that he has not overcome the effects of these impairments through further education, transferable skills, or obtaining and maintaining work. She noted that the Veteran has difficulty trusting and working with others as well as coping with stressful situations due to his PTSD and has limitations with lifting as a result of his service-connected lumbar strain disability. Additionally, the August 2015 VA PTSD examiner noted that the Veteran’s PTSD symptoms included difficulty in establishing and maintaining effective work and social relationships; mild memory loss such as forgetting names, directions, or recent events; suspiciousness; disturbances of motivation and mood; and chronic sleep impairment. The examiner noted that the Veteran had tried vocational rehabilitation and had previously worked sporadically, under the table, in lawn service and washing cars but had not formally worked since his separation from the military. The August 2018 VA spine examiner also determined that the Veteran’s service-connected low back disability impacted his ability to work because the Veteran had physical limitations with prolonged standing and sitting. Although the examiner found the Veteran did not have sedentary limitations, the Board finds that limitations with prolonged sitting would impact sedentary work opportunities. In light of the foregoing, and given the Veteran’s educational and vocational background, the evidence of record suggests that the Veteran is unable to follow substantially gainful employment due to his service-connected disabilities. Specifically, the Veteran’s ability to perform physical or sedentary work has been severely impaired due to his PTSD, migraine headaches, and lumbar strain disabilities, impacting both physical and mental capabilities. To the degree that the Veteran would be able to perform less physical work (despite his low back disability affecting his ability to sit for prolonged periods), the Board finds that from a practical standpoint, the Veteran would be too limited to perform such occupations due to his service-connected PTSD. The totality of his mental health symptoms, including memory issues, chronic sleep impairment, disturbances in motivation and mood, indicate the Veteran would be significantly impeded in workplace productivity based on his PTSD symptoms alone. Conversely, to any degree that the Veteran may be able to maintain some occupations despite his psychiatric disorder, he would be rendered unemployable in these positions due to the physical limitations resulting from his other service-connected disabilities. Thus, the Board finds that entitlement to a TDIU for the entire appeal period is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for bilateral hearing loss The Veteran contends that he has bilateral hearing loss as a result of noise exposure during service. The Veteran was afforded a VA examination in August 2018 to assess his hearing. The examiner noted that the Veteran’s military history was positive for noise exposure but found that the Veteran’s puretone threshold levels did not reflect bilateral hearing loss. However, the Veteran reported that his hearing loss has worsened since his last VA examination in 2018. See February 2020 Brief. Specifically, the Veteran reported increased difficulty understanding people during conversation and difficulty hearing in crowds. Id. VA’s duty to assist includes the conduct of a thorough and comprehensive medical examination. Robinette v. Brown, 8 Vet. App. 69, 76 (1995). In light of the Veteran’s assertions that his hearing has worsened, in conjunction with the amount of time that has passed since his last VA examination, the Board finds the Veteran should be scheduled for another VA examination to determine whether he has a current hearing loss disability for service connection purposes under 38 C.F.R. § 3.385. 2. Entitlement to an initial rating in excess of 10 percent for a lumbar strain The Veteran contends that he is entitled to an increased rating for his lumbar strain disability. The Board notes that for increased rating musculoskeletal claims, VA examiners are required to include joint testing for pain on active and passive motion and in weight-bearing and non-weight-bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016); 38 C.F.R. § 4.59. Additionally, for increased rating musculoskeletal claims, VA examiners should obtain information from the Veteran regarding the severity, frequency, duration, characteristics, and/or functional loss related to repeated use over time and/or flare-ups. If the examination was not conducted after repeated use over time or during a flare-up, the examiner should provide an opinion based on estimates derived from this information from the veteran as to the additional loss of range of motion that may be present. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). In the present case, the Veteran was last afforded a VA examination for his lumbar strain in August 2018. Unfortunately, the Board concludes that his examination is not compliant with the requirements of Correia and Sharp nor the January 2017 Board remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, the August 2018 VA examiner did not indicate where pain began on range of motion measurements. Additionally, although the Veteran reported flare-ups in the form of intermittent pain with prolonged standing and sitting lasting several hours, the examiner determined that pain, weakness, fatigability, or incoordination do not significantly limit functional ability with flare-ups and did not provide range of motion estimates during flare-ups. The examiner provided no rationale for this opinion and his determination contradicts the Veteran’s reports and other medical evidence of record reflecting functional limitations during flare-ups. Accordingly, a remand is warranted so that the Veteran is afforded an adequate VA examination that appropriately reflects the severity of his current disability. 3. Entitlement to an initial rating in excess of 30 percent for migraine headaches The Veteran contends that he is entitled to an increased rating for his service-connected migraine headaches. Unfortunately, the Board cannot make a fully informed decision on the Veteran’s increased rating claim because the last VA examination of record, in July 2015, is inadequate. In this regard, during the July 2015 VA examination, the Veteran reported experiencing episodes two to three times a week of varying intensity lasting up to a day. However, the examiner indicated that the duration of the Veteran’s migraine headaches was less than a day and that prostrating attacks occur once every month. The examiner also indicated that the Veteran did not have very prostrating and prolonged attacks of migraine/non-migraine pain productive of severe economic inadaptability and found that the Veteran’s headache condition does not impact his ability to work. The examiner provided no rationale for these opinions, which also contradict the Veteran’s reports that his migraines are a barrier to his employment. See August 2012 and June 2014 VA Vocational Rehabilitation Applications. The Board finds that another VA examination is necessary to determine the functional impact of the Veteran’s migraine headaches on his ability to work as well as the frequency of his prostrating migraine attacks. Additionally, in December 2015, the Veteran reported that he currently experienced three to four headaches a week, that the headaches can last up to a whole day, and that Ibuprofen is only partially effective. This reflects a potential increase in frequency and severity of his headaches. As such, another VA examination is necessary to determine the current severity of the Veteran’s disability since his last VA examination in July 2015. The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran’s claims for any and all outstanding VA treatment records. The last VA treatment of record is dated November 2018. 2. Provide the Veteran with an opportunity to identify any outstanding private records relevant to his claims. After obtaining any necessary authorization from the Veteran, any outstanding treatment records, should be obtained. 3. Then, schedule the Veteran for a VA audiology examination by an appropriate medical professional to address the claimed bilateral hearing loss. The record, to include a copy of this remand, must be reviewed by the VA examiner. The examiner should identify whether the Veteran currently has bilateral hearing loss. The audiological examiner should obtain the Veteran’s auditory thresholds at frequencies of 500, 1000, 2000, 3000, and 4000 Hertz, as well as speech recognition scores based on the Maryland CNC tests to determine whether the Veteran has impaired bilateral hearing pursuant to 38 C.F.R. § 3.385. For any diagnosed hearing loss, the examiner should opine as to whether it is at least as likely as not (i.e. a 50 percent or greater probability) the hearing loss had its onset in or was otherwise incurred in service, to specifically include the competently reported in-service noise exposure. The examiner is notified that the Veteran is competent to report as to the onset and continuity of symptomatology of the claimed right ear hearing loss. A complete rationale should be given for all opinions and conclusions expressed. The examiner should address the bilateral threshold shift documented in the Veteran’s STRs and the Veteran’s reports of functional impact from his hearing loss, to include difficulty understanding people when they talk and difficulty hearing in crowds. See February 2020 Brief. 4. Schedule the Veteran for an updated VA examination to determine the severity of his service-connected lumbar strain. The claims file, to include a copy of this Remand, should be made available to and be reviewed by the examiner. All indicated testing should be accomplished and all symptomatology associated with the spine disability should be identified. Specifically, the examiner should address whether the Veteran has any radicular symptomatology associated with his lumbar strain. The Veteran has reported back pain that radiates to his legs. See April 2010 VA treatment note. (a) The examiner must test the Veteran’s range of motion on BOTH active and passive motion, on weight-bearing and non-weight-bearing, if possible. (b) If there is evidence of pain on motion, the examiner must indicate the degree of range of motion at which such pain begins, and whether such pain on movement, as well as weakness, excess fatigability, or incoordination results in any loss of range of motion. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain so in the report. (c) It is also imperative that the examiner comment on the functional limitations caused by flare-ups and repetitive use due to the Veteran’s disability. The examiner should state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups, if any, he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of his neck and/or after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. (d) If it is not feasible to determine the extent to which the Veteran experiences additional functional loss on repeated use over time or during flare-ups without resorting to speculation, the examiner must provide an explanation for why that is so. The examiner is further advised that the inability to provide an opinion without resorting to speculation must be based on the limitation of knowledge in the medical community at large and not a limitation - whether based on lack of expertise, insufficient information, or unprocured testing - of the individual examiner 5. Schedule the Veteran for an updated VA examination to ascertain the severity and manifestations of the Veteran’s service-connected migraine headaches. The claims file, to include a copy of this Remand, should be made available to and be reviewed by the examiner. The examiner is requested to review all pertinent records associated with the claims file and the Veteran’s reports regarding the severity, frequency, and duration of his migraine headaches. The examiner should provide a full description of the disability and report all signs and symptoms necessary for rating the disability under the rating criteria. Specifically, the examiner should indicate the frequency and duration of any prostrating attacks and opine, with rationale, as to the functional impact of his migraine headaches on his ability to work. The examiner should provide a clear explanation for all conclusions reached. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Amanda Purcell, Associate 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.