Citation Nr: 21002565 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 15-27 247A DATE: January 14, 2021 ORDER A disability evaluation of 10 percent, but no greater, for Raynaud's Syndrome is granted throughout the entire appeal period. A rating in excess of 20 percent disabling for the service-connected back disability is denied. Entitlement to a TDIU is granted, effective November 16, 2013. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's service-connected Raynaud's syndrome was manifested by characteristic attacks occurring no more than 1 to 3 times a week. 2. The Veteran's back disability manifested by pain and limitation of flexion of the thoracolumbar spine to, at most, 35 degrees. 3. Since November 16, 2013, the Veteran has been unable to secure or maintain substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a disability evaluation of 10 percent, but no higher, for Raynaud's Phenomenon have been met throughout the appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1-4.16, 4.30, 4.104, Diagnostic Code 7117. 2. The criteria for a disability rating in excess of 20 percent for a lumbar spine disability have not been met. 38 U.S.C. § 1137, 1155 (2012); 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242-5243 (2017). 3. The criteria for a TDIU have been met effective November 16, 2013. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.159, 3.340, 3.341, 4.1, 4.3, 4.15, 4.16, 4.18, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service in the United States Army from January 1982 to January 2002. She was awarded the Army Commendation Medal and Army Achievement Medal, among other decorations, for this service. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A copy of the transcript has been associated with the electronic claims file. The appeal initially included the issue of entitlement to service connection for posttraumatic stress disorder (PTSD). In an August 2020 rating decision, the RO granted service connection for PTSD constituting a full grant of the benefit sought (service connection for PTSD); therefore, that issue is not in appellate status, and is not before the Board because there remain no questions of law or fact as to the fully granted issue. See 38 U.S.C. § 7104 (2012) (stating that the Board decides questions of law or fact). In December 2019, the Board remanded the claims for service connection for further development, including examinations. The Board notes that in a November 2020 statement the Veteran indicated that she was unable to schedule VA examinations, however, review of the record indicates the Veteran underwent all of the requested examinations for the issues currently before the Board. As such, after review of the record, the Board finds that there has been substantial compliance with the development sought as part of the December 2019 remand. Stegall v. West, 11 Vet. App. 268 (1998). Finally, the Board notes the Veteran has submitted statements suggesting she wishes to file claims based on clear and unmistakable error for the effective dates of Raynaud’s disease and PTSD, as well as, termination of a dependent. VA amended its adjudication regulations on March 24, 2015, to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. 79 Fed. Reg. 57660 (Sept 25, 2014). Therefore, if the Veteran wishes to file the earlier effective date and termination of a dependent claims, the appropriate forms should be submitted. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." See Fenderson v. West, 12 Vet. App. 119 (1999). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify."). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A veteran as a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau at 1372). Raynaud’s Phenomenon The Veteran contends the service-connected Raynaud's phenomenon is more severe than the initial noncompensable evaluation reflects. On remand, an August 2020 rating decision granted an increased evaluation to 10 percent, effective February 7, 2020. 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. AB v. Brown, 6 Vet. App. 35 (1993). After review of the entire record, and resolving all doubt in favor of the Veteran, the Board finds that his service-connected Raynaud's phenomenon more closely approximates the 10 percent rating throughout the entire appeal period. The Veteran's Raynaud's phenomenon is currently rated under Diagnostic Code 7117. Under Diagnostic Code 7117, a 10 percent rating is warranted where characteristic attacks occur one to three times a week. A 20 percent rating is warranted where characteristic attacks occur four to six times a week. A 40 percent rating is warranted where characteristic attacks occur at least daily. A 60 percent rating is warranted where there are two or more digital ulcers and a history of characteristic attacks. A 100 percent rating is warranted where there are two or more digital ulcers plus autoamputation of one or more digits and a history of characteristic attacks. 38 C.F.R. § 4.104. A characteristic attack consists 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. 38 C.F.R. § 4.104, Diagnostic Coe 7117, Note. In August 2009 the Veteran filed for an increased evaluation of the service-connected Raynaud’s phenomenon. In February 2010, the Veteran underwent a VA examination to determine the severity of the service-connected Raynaud’s phenomenon. She reported pain in her hands that lasted 10 to 15 minutes when the temperature got below 73 degrees with no color change. To treat the Raynaud’s phenomenon, she would take her hands out of the cold and there were no current medications or surgeries for the disability. On examination, the Veteran’s hands and feet had no color, there were no ulcers, and radial pulse was 2+ in both the upper and lower extremities. While the Veteran’s claims file was unavailable for review during the examination, the Board finds the examination adequate for the purposes of an increased evaluation claim because the question is the current level of disability and the examiner was provided an accurate history of the condition. Further, the Board finds additional remand unnecessary because any further development regarding the 2010 examination would require speculation on the severity of the Veteran’s disability 11 years ago and would which would require a physician to make a retrospective opinion unnecessarily when the Board has access to the same records the physician would. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (remand is unnecessary where it "would result in this Court's unnecessarily imposing additional burdens on the [Board and the Secretary] with no benefit flowing to the Veteran."). In her July 2008 notice of disagreement, the Veteran indicated that she felt her Raynaud’s phenomenon affected her without exposure to cold and affected her for hours on a daily basis. During a September 2019 Board hearing, the Veteran reported that when exposed to cold she experienced pain, discoloration, and numbness. The Veteran further indicated these attacks could occur between once a week and everyday depending on cold exposure. In February 2020, the Veteran underwent an additional examination to determine the severity of the service-connected Raynaud’s phenomenon. The Veteran reported that the disability was unchanged, and she experienced numbness and burning pains on her toes and fingers when exposed to temperatures below 75 degrees. On examination, the Veteran had no digital ulcers and had undergone no amputations due to the service-connected Raynaud’s phenomenon. The VA examiner indicated the Veteran experienced characteristic attacks 1 to 3 times per week. VA and private treatment records throughout the appeal period are consistent with the VA examination of record. After review of the lay and medical evidence, and resolving all doubt in the Veteran’s favor, the Board finds that the service-connected Raynaud's phenomenon most closely approximates the 10 percent disability rating criteria throughout the entire appeal period. This rating criteria encompasses attacks occurring one to three times per week. Here there is credible and competent evidence of episodes occurring at least once a week, depending on cold exposure. Further, during the February 2020 VA examination, the Veteran reported that the disability was unchanged which the Board interprets to mean the Veteran’s symptoms have been consistent throughout the appeal period. A higher rating would require more frequent episodes or ulcers resulting on the Veteran's fingers. There is no evidence to indicate the Veteran experiences attacks more frequently than three times per week, nor is there evidence, lay or medical, that indicates the Veteran's fingers have any ulcers on them. Therefore, a disability rating of 10 percent, but no higher is warranted for the Veteran's Raynaud's phenomenon throughout the entire appeal period. Back Disability The Veteran contends that the back disability warrants a higher rating evaluation throughout the appeal period. After review of the lay and medical evidence, the Board finds that an evaluation in excess of 20 percent for the service-connected back disability is denied. Where functional loss due to pain on motion is alleged, 38 C.F.R. §§ 4.40 and 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court held that consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. The Court held that pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination and endurance to constitute functional loss. Mitchell v. Shinseki, 24 Vet. App. 32, 33, 43 (2011). Although pain may cause functional loss, pain, itself, does not constitute functional loss and is just one factor to be considered when evaluating functional impairment. Id. The Court explained in Mitchell that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Consequently, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board notes, however, that the Court has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). The Veteran's service-connected back disability is evaluated under Diagnostic Codes 5242 for degenerative arthritis of the spine. The General Rating Formula for Diseases and Injuries of the Spine provides that, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees, but not greater than 40 degrees; or, combined range of motion of the entire thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees; or, combined ranges of motion of the entire cervical spine greater than 170 degrees, but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. Id. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (for DCs 5235 to 5243). The criteria also include the following provisions: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The Veteran asserts that the lumbar spine disability was more disabling than reflected by the 20 percent disability evaluation. By history, in August 2009 the Veteran filed for an increased evaluation of the service-connected back disability. In February 2010, the Veteran underwent a VA examination to determine the severity of the service-connected back disability. She reported constant moderate to severe pain with bilateral radiation that included numbness, tingling, paresthesia, and dysesthesia. The Veteran reported no incapacitating episodes in the last year but did report stiffness, spasm, weakness, numbness, and bowel and bladder incontinence that occurred two times per week. She estimated 120 days of employment were lost in the last year from the service-connected back disability. On examination, range of motion testing revealed 65 degrees of forward flexion, 10 degrees of extension, 25 degrees of left and right lateral flexion, and left and right lateral rotation of 30 degrees. After repetitive testing, range of motion testing revealed 65 degrees of forward flexion, 10 degrees of extension, 25 degrees of left and right lateral flexion, and left and right lateral rotation of 30 degrees. There was no objective evidence of pain, spasm, weakness, atrophy, or guarding. Deep tendon reflexes were 2+/4 bilaterally. Inspection of the lumbar spine revealed no erythema, swelling, or tenderness to palpitation. The VA examiner diagnosed the Veteran with bilateral lumbar paraspinal muscle strain with bilateral lower extremity paresthesias/dysesthesia. In her July 2008 notice of disagreement, the Veteran indicated she experienced radiating pain down her legs that included numbness and tingling. In December 2015, the Veteran underwent an additional VA examination to determine the severity of the service-connected back disability. On examination, range of motion testing revealed 40 degrees of forward flexion, 15 degrees of extension, 15 degrees of left and right lateral flexion, and left and right lateral rotation of 20 degrees which was unchanged after repetitive testing. The VA examiner indicated the Veteran had muscle spasms that did not affect gait and no ankylosis. In April 2019, the Veteran underwent an additional examination for the service-connected back disability. She reported sharp low back pain that occurred when sitting, laying down, and bending forward without flare-ups. On examination, range of motion testing revealed 40 degrees of forward flexion, 10 degrees of extension, right lateral flexion was 15 degrees, left lateral flexion was 10 degrees, and left and right lateral rotation of 20 degrees which was unchanged after repetitive testing. There was objective pain with functional loss on examination and pain with weight bearing. The VA examiner indicated it was not possible to describe any additional range of motion during a flareup because there was no change from the initial measurements following repetitive testing. The Veteran had no guarding or spasm on examination and strength testing was normal and there was no ankylosis of the lumbar spine. In August 2020, the Veteran underwent an additional examination to determine the severity of the back disability. She reported peristent aching, sharp, and throbbing pain daily which was worsened with certain movements. The Veteran did not report flare-ups of the back disability. On examination, range of motion testing revealed 45 degrees of forward flexion, 15 degrees of extension, right and left lateral flexion was 25 degrees, and left and right lateral rotation of 30 degrees. After repetitive testing, range of motion testing revealed 45 degrees of forward flexion, 15 degrees of extension, right and left lateral flexion was 25 degrees, and left and right lateral rotation of 30 degrees. There was objective pain with functional loss on examination and pain with weight bearing. The VA examiner did not describe any additional range of motion during a flareup because the Veteran denied flareups. The Veteran had no guarding or spasm on examination and strength testing was normal and there was no ankylosis of the lumbar spine. The Veteran did not have IVDS or ankylosis of the lumbar spine. As noted above, a 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. VA and private treatment records throughout the appeal period are consistent with the VA examinations of record. The Veteran has continually reported pain and functional impairment due ot the service-connected back disability. The Board has considered whether a disability rating higher than 20 percent is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. Although the Veteran's symptoms included pain on movement the VA examination reports indicated that the Veteran had forward flexion to at least 35 degrees even after three repetitions of repetitive-use testing. In sum, even considering the effects of pain, the Veteran retained ranges of motion in the thoracolumbar spine that more closely approximate the 20 percent evaluation criteria. In other words, any additional limitation due to pain does not more nearly approximate a finding of forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Accordingly, the 20 percent rating contemplates the functional loss due to pain and less movement. There is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness or incoordination for this period of the appeal. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 206-07. The Board has also considered separate rating for any additional neurological disabilities during any period of the appeal. The Board notes the Veteran is already separately rated for moderate bilateral lower extremity radiculopathy. The Veteran has also had no surgeries on the back that would produce a scar warranting a separate evaluation. Finally, the Board notes two reports in the record of bowel and bladder incontinence but finds that the preponderance of the evidence is against a finding of a separate rating for a secondary bowel or bladder disability. Specifically, during the February 2010 VA examination, the Veteran reported bowel issues and a March 2017 MRI indicated that it was for chronic pain and loss of control bowel. However, the Veteran denied bowel or bladder issues in December 2015, April 2019, August 2020, and the Board finds no other indications of current bowel or bladder issues in the record including the September 2019 Board testimony. Accordingly, separate evaluations are not warranted for any other neurological conditions. In sum, the preponderance of the evidence is against the award of a rating in excess of 20 percent for the Veteran's lumbar spine disability at any point during the appeal period. As a preponderance of the evidence is against the award of an increased evaluation for this period of the appeal, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. TDIU The Veteran contends that she is unable to secure or maintain employment due to his service-connected disabilities. In March 2019, the Veteran field a formal claim for a TDIU, however, entitlement to total disability evaluation based on individual unemployability is an element of all increased rating claims. See Rice v. Shinseki, 22 Vet. App. 447 (2009). As such, the Board finds the Veteran’s increased rating claim encompassed a claim for TDIU and as such, the Veteran’s service-connected disabilities have prevented her from maintaining substantially gainful employment since November 16, 2013. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. 38 C.F.R. § 3.340(a)(1) (2017). Total ratings are authorized for any disability or combination of disabilities for which the Rating Schedule prescribes a 100 percent evaluation. 38 C.F.R. § 3.340(a)(2). A TDIU may be assigned when the disabled veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Individual unemployability must be determined without regard to any non-service-connected disabilities or a veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19, Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether a veteran can find employment. Id. at 361. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a veteran's favor. 38 C.F.R. § 4.3. In Faust v. West, 13 Vet. App. 342 (2000), the Court defined "substantially gainful employment" as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran's earned annual income. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to TDIU is whether a veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). In evaluating a veteran's employability, consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion, but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Marginal employment is not considered substantially gainful employment and generally is deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist in certain cases when earned annual income exceeds the poverty threshold on a facts-found basis. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). Marginal employment, odd-job employment, and employment at half the usual remuneration is not incompatible with a determination of unemployability if the restriction to securing or retaining better employment is due to disability. See 38 C.F.R. § 4.17(a) (2017). The Veteran contends that she is unable to secure or maintain employment due to his service-connected disabilities. Throughout the entire appeal period, the Veteran has been service-connected for posttraumatic stress disorder, evaluated at 70 percent, degenerative disc disease of the lumbar spine, evaluated at 20 percent, sciatic radiculopathy, right lower extremity, evaluated at 20 percent, tinnitus, evaluated at 10 percent, Raynaud’s phenomenon, evaluated at 10 percent, and emphysema evaluated at a noncompensable rating. Her combined evaluation has been 90 percent throughout the entire appeal period and the Veteran has met the schedular requirements for a TDIU rating under 38 C.F.R. § 4.16(a). The Board find the combined effects of the service-connected disabilities has prevented the Veteran from maintaining substantially gainful employment since November 16, 2013. The record shows the Veteran stopped working on November 15, 2013. The Board notes the Veteran indicated on her VA Form 21-8940 that she stopped working both because her contract ended and because of her service-connected disabilities. However, the only question before the Board is whether the service-connected disabilities prevent the Veteran from maintaining substantially gainful employment and, after review of the lay and medical evidence, the Board finds they do. First, the record consistently shows the Veteran’s Raynaud’s phenomenon presents with numbness and burning pains on her toes and fingers when exposed to temperatures below 75 degrees. Next, the Veteran’s service-connected PTSD was found to result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood throughout the appeal period. The Veteran has reported social isolation and that she very rarely leaves the house except for medical appointments. Finally, the Veteran has reported, and the record supports, that her service-connected back disability and right leg radiculopathy have further contributed to her inability to maintain substantially gainful employment. As discussed above the back disability results in pain, muscle spasm, and numbness in the right leg that severely impact the Veteran’s ability to walk for long periods of time. The Board also notes that May 2017, the Social Security Administration found the Veteran unemployable due to lumbar degenerative disc disease and depression. Accompanying medical records show the Veteran continues to receive treatment for the service-connected disabilities. Finally, the Board finds the lay evidence, including the Veteran’s multiple statements and testimony, as well as, multiple buddy statements documenting the severity and impact of the service-connected disabilities persuasive. Based on the above, the Board finds that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. Specifically, reviewing the evidence above reflects that the Veteran worked in security and as a defense analyst for 11 years before retiring due to the service-connected disabilities. The Veteran has indicated 4 years of college with no additional training or education. Next, the lay and medical evidence of record supports a finding that the Veteran's PTSD, back disability with right leg radiculopathy, and Raynaud’s phenomenon severely impact her ability to maintain substantially gainful employment. The Veteran has reported social isolation, difficulties with walking, standing, sitting, nad pain when in temperatures below 73 degrees, because of the service-connected disabilities. Furthermore, both VA and private examiners have indicated that the Veteran's service-connected disabilities impact her ability to maintain substantially gainful employment. Therefore, considering the entire record in light of the above, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the evidence supports the assignment of a TDIU due to service-connected disabilities. 38 C.F.R. § 4.16(a). Neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Teague, 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.