Citation Nr: 21002972 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 11-08 122 DATE: January 19, 2021 ORDER Entitlement to service connection for a bilateral shoulder disability is granted. Entitlement to service connection for a cervical spine disability, as secondary to service-connected lumbar discogenic disease, is granted. Entitlement to service connection for a bilateral ankle disability, as secondary to service-connected lumbar discogenic disease, is granted. Entitlement to service connection for a bilateral knee disability, as secondary to lumbar discogenic disease, is granted. Entitlement to service connection for a bilateral hip disability, as secondary to lumbar discogenic disease, is granted. Entitlement to service connection for a hiatal hernia is granted. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Resolving all reasonable doubt in his favor, the Veteran’s bilateral shoulder disability is causally or etiologically due to service. 2. Resolving all reasonable doubt in his favor, the Veteran’s cervical spine disability is proximately due to his service-connected lumbar discogenic disease. 3. Resolving all reasonable doubt in his favor, the Veteran’s bilateral ankle disability is proximately due to his service-connected lumbar discogenic disease. 4. Resolving all reasonable doubt in his favor, the Veteran’s bilateral knee disability is proximately due to his service-connected lumbar discogenic disease. 5. Resolving all reasonable doubt in his favor, the Veteran’s bilateral hip disability is proximately due to his service-connected lumbar discogenic disease. 6. The evidence of record does not satisfactorily prove or disprove that the Veteran’s hiatal hernia had an onset during service or is otherwise etiologically related to symptomatology noted in service. 7. The Veteran does not have a current diagnosis of PTSD. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a bilateral shoulder disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for a cervical spine disability, as secondary to service-connected lumbar discogenic disease, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for entitlement to service connection for a bilateral ankle disability, as secondary to service-connected lumbar discogenic disease, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for entitlement to service connection for a bilateral knee disability, as secondary to service-connected lumbar discogenic disease, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for entitlement to service connection for a bilateral hip disability, as secondary to service-connected lumbar discogenic disease, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 6. The criteria for entitlement to service connection for a hiatal hernia are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for PTSD, to include as secondary to any service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1980 to June 1981 and December 1990 to June 1991. The Veteran served in Southwest Asia from January 1991 to March 1991. This matter comes before the Board of Veterans’ Appeals (BVA or Board) from May 2010, December 2011, April 2013 and April 2018 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In September 2016 and February 2020, the Board remanded these claims for additional development. Service Connection The Veteran seeks entitlement to service connection for a cervical spine, bilateral shoulder, bilateral ankle, bilateral knee, and bilateral hip disabilities. He also seeks entitlement to service connection for a hiatal hernia and PTSD. Under the relevant laws and regulations, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). In general, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Alternatively, service connection may be established under 38 C.F.R. § 3.303 (b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The theory of continuity of symptomatology is an alternative route to establish service connection for specific chronic diseases and can only be used in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established for disability that is proximately due to or the result of a service-connected disability, or for any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the nonservice-connected disease. 38 U.S.C. § 1110; 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, there must be evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 4 (1990). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for a bilateral shoulder disability. The Veteran has a diagnosis of bilateral shoulder impingement syndrome, left shoulder supraspinatus tendonitis, and bilateral degenerative changes of the AC-joints. As such, Shedden element (1), current diagnosis, is met. The Veteran asserts that he began experiencing bilateral shoulder pain during service, related to heavy weight handling. He asserts he gradually developed less ability to do pushups and less strength at the shoulders. See July 2011 VA examination. A statement from a private physician, received in March 2008, states that the Veteran served as a practical nurse in his medical company while in the Persian Gulf War. The letter asserts that in addition to the Veteran’s equipment weight of more than 40 pounds, he had to help carry injured patients while in Kuwait, which required heavy physical effort, despite being on a profile to limit the amount of weight he was supposed to lift. See March 2008 statement from Dr. R. Personnel records confirm that the Veteran served in the Persian Gulf War and that his military occupational specialty (MOS) was a practical nurse and medical specialist. Records also contain a physical profile stating that from January 1991 to April 1991, the entire period he was in Southwest Asia, the Veteran was to only wear his helmet and lift a maximum of 10 pounds. See January 1991 DA Form 3349. The Veteran’s reported duties of carrying equipment and injured patients are consistent with his MOS; the Board finds that Shedden element (2) is met. Regarding element (3), nexus, in September 2008, a private physician, Dr. R., opined that the weight the Veteran carried on his shoulders during service caused inflammatory changes. Similarly, in December 2009, a private physician, Dr. V., also asserted that the weight the Veteran carried on his shoulder caused inflammatory changes in the shoulders. In July 2011, a VA examiner opined that the Veteran’s bilateral shoulder impingement syndrome and left shoulder supraspinatus tendinitis were related to musculoskeletal overuse etiology. Although an addendum opinion was obtained in August 2020, the opinion only pertained to the Veteran’s degenerative arthritis and did not discuss his other diagnoses of bilateral shoulder impingement syndrome and left shoulder supraspinatus tendonitis. It was opined that the Veteran’s bilateral shoulder disorder was not due to service as there was no evidence of shoulder pain, complaints or treatment during service; however, the examiner failed to note and discuss the Veteran’s lay statements regarding the onset of pain and weakness during service. There was also no discussion of the Veteran’s theory that his bilateral shoulder disorder was due to repetitive heavy lifting during service. Here, the Board resolves doubt in favor of the Veteran and finds that the evidence is at least in equipoise that his current bilateral shoulder disorders are due to his time in service. As noted, the Veteran asserts that despite being placed on a physical profile, as a nurse during service he was required to carry heavy equipment and patients, and two private medical physicians, Dr. R. and Dr. V., opined that the Veteran’s inflammatory changes of the shoulders are due to carrying heavy equipment and patients during service. Additionally, the July 2011 VA examiner opined that the Veteran’s diagnosed bilateral shoulder impingement syndrome and left shoulder supraspinatus tendonitis were due to musculoskeletal overuse. Although the July 2011 VA examiner did not specify whether the overuse occurred during service, the Board resolves all reasonable doubt in the Veteran’s favor, and considering the evidence as whole, finds that the evidence is at least in equipoise that the Veteran’s bilateral shoulder disability is causally or etiologically due to his time in service. The Veteran has current diagnoses, reported duties during service consistent with his verified MOS during service, and medical opinions linking his current diagnoses to his duties during service. As such, the Veteran’s service connection claim for a bilateral shoulder disability is granted. 2. Entitlement to service connection for a cervical spine disability. 3. Entitlement to service connection for a bilateral ankle disability. 4. Entitlement to service connection for a bilateral knee disability. 5. Entitlement to service connection for a bilateral hip disability. The Veteran asserts his cervical spine, bilateral ankle, bilateral knee, and bilateral hip disabilities are secondary to his service-connected lumbar spine disability and/or radiculopathy of the bilateral lower extremities. The Board also acknowledges that the Veteran has asserted he began experiencing left hip pain during service. Because the Board is granting these claims on a secondary basis based on causality, it will not discuss direct service connection in this section. The Veteran has current diagnoses of cervical degenerative discs and apophyseal degenerative joint disease, degenerative arthritis of the bilateral ankles and bilateral knees, and degenerative joint disease of the bilateral hips. See February 2017 VA examinations. As such, element (1) set forth under Allen, current disability, has been satisfied for each appeal. The Veteran is service connected for lumbar discogenic disease and currently has a rating of 40 percent. See October 2016 rating decision; April 2018 rating decision. The Board finds that the evidence is at least in equipoise that his cervical spine, bilateral ankle, bilateral knee and bilateral hip disorders are proximately due to his service-connected lumbar spine disability. In a December 2009 statement, Dr. V. opined that it was more probable than not that the Veteran’s neck, knee, hip, and ankle problems were caused by his back problems. The physician explained that carrying heavy weight during service applied stress to the major articulations of the back, causing chronic inflammatory changes with subsequent degenerative changes. These changes also caused bad posture, loss of correct alignment and loss of curvature of the cervical, thoracic, and lumbar lordosis, which puts more stress on one side of the vertebras than the other and could present disc bulging, herniation, and degenerative problems. Continuing, the physician stated that as a consequence, the Veteran’s neck and back is affected and secondary to these problems, degenerative changes could be present in other articulations, such as the hips, knees, and ankles. The physician then stated that these changes also cause weight bearing problems, which put stress in the knees and ankles. These issues were remanded by the Board in September 2016. The RO failed to obtain adequate medical opinions as directed by the Board and the issues were remanded again in February 2020. Of note, the February 2020 VA medical opinions opine that the Veteran’s cervical spine, ankle, hip, and knee disorders are due to aging. The VA medical opinions state that the private medical opinions of record linking the Veteran’s disorders to his lumbar spine disability are speculative and that the Veteran’s cervical spine, bilateral ankle, hip and knee disorders are not related to his back in terms of anatomy, biomechanics or pathophysiology. The February 2020 VA examiner stated that the private physician’s opinion has no medical literature basis or evidence to claim that the Veteran’s lumbar spine disability can cause or aggravate his cervical spine, knee, hip, or ankle disorders. The Board notes, however, that the February 2020 VA examiner fails to offer any medical literature basis or evidence to claim that the Veteran’s lumbar spine does not cause or aggravate his cervical spine, bilateral knee, hip or ankle disorders. The February 2020 VA examiner fails to specifically discuss or offer medical literature contradicting the private physician’s rationale that the Veteran’s lumbar spine disability causes bad posture, loss of curvature of the cervical spine, causes loss of correct alignment, which puts more stress on one side of the vertebras than the other and ultimately weight bearing problems affecting the ankles and knees. The Board acknowledges there are inadequacies in both the private and VA medical opinions obtained. However, in light of the discussion above, while the evidence is not unequivocal, it has nonetheless placed the record in relative equipoise. The Board finds that an additional remand to obtain a third addendum opinion would likely serve no benefit to the Veteran. Accordingly, the Board finds that element (2) under Allen, nexus, has been satisfied and the appeals for entitlement to service connection for a cervical spine disability, a bilateral knee disability, a bilateral ankle disability, and a bilateral hip disability are granted, as proximately due to his service-connected lumbar spine disability. 6. Entitlement to service connection for a hiatal hernia. The Veteran seeks entitlement to service connection for a hiatal hernia. Specifically, he claims that his hiatal hernia developed or became worse while in service in Southwest Asia. The medical evidence reflects that the Veteran is diagnosed with a hiatal hernia, post service. See August 2020 VA examination. Thus, the Veteran has a current disability for VA purposes. With respect to element (2), a relevant in-service event, injury or disease, the Board notes there is some evidence of hiatal hernia symptoms during the Veteran’s service. Shortly after entering active duty, a December 1990 consultation sheet indicates the Veteran had a barium esophagram done in Puerto Rico, which demonstrated a 62.5-centimeter hiatal hernia without evidence of gastroesophageal reflux. It was noted that the Veteran was told to take Zantac but did not currently, and that his stomach and duodenal bulb were all normal. He was cleared for deployment but given prophylactic Zantac. A May 1991 service treatment note reported a prior history of gastroesophageal reflux disease. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has distinguished between those cases in which the pre-existing condition is noted upon entry into service, and those cases in which the pre-existence of the condition must otherwise be established. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); Horn v. Shinseki, 25 Vet. App. 231, 234 (2012); see also 38 U.S.C. § 1111 (presumption of sound condition). In a case where there is no preexisting condition noted upon entry into service, the Veteran is presumed to have entered service in sound condition, and the burden falls to the government to demonstrate by clear and unmistakable evidence that (a) the condition preexisted service and (b) the preexisting condition was not aggravated by service. Wagner, 370 F3d. at 1345; Horn, 25 Vet. App. at 234; 38 U.S.C. § 1111. To be “noted” within the meaning of the presumption of soundness statute, the condition must be recorded in the entrance examination report. 38 C.F.R. § 3.304 (b); see also 38 U.S.C. § 1111; Crowe v. Brown, 7 Vet. App. 238, 245 (1994). History of pre-service existence of a disease does not constitute a notation of such condition. See id. at 240 (holding that “asthma” was not noted where, although the Veteran checked a box indicating that he had a history of the disease, a clinical evaluation detected no abnormalities of the lungs). However, the disease need not be symptomatic at the time of the evaluation, so long as a diagnosis is provided. See Verdon v. Brown, 8 Vet. App. 529, 530 (1996) (holding that “bunions” were noted at induction examination where orthopedic examiner diagnosed “bunions,” despite also stating “no problem [with] feet.”). In this case, the December 1989 examination, closest to the time period in question, shows that the Veteran did not have a hiatal hernia noted. The reports are absent for any indication or complaints of hiatal hernia type symptoms. Accordingly, the presumption of soundness applies to the Veteran’s hiatal hernia, as it was not noted on the examination prior to the period of active service in question. Therefore, if the Board is to find that the presumption of soundness is rebutted and that the Veteran’s hiatal hernia pre-existed service, it must find (1) that clear and unmistakable evidence shows that a hiatal hernia pre-existed service; and (2) that clear and unmistakable evidence shows that his hiatal hernia was not aggravated by service. Horn, 25 Vet. App. at 234. Here, the evidence of a pre-existing condition consists of statements by the Veteran both prior to service and in the course of his post-service treatment. However, the United States Court of Appeals for Veterans Claims (Veterans Court) has consistently held that a Veteran’s lay account of a prior condition does not amount to a clinical diagnosis, and may not by itself allow for the conclusion that there is clear and unmistakable evidence that a condition pre-existed service. See Crowe, 7 Vet. App. at 245; Paulson v. Brown, 7 Vet. App. 466, 470 (1995). The Board emphasizes that clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that “clear and convincing” burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an “onerous” evidentiary standard. Cotant v. West, 17 Vet. App. 116, 131 (2003) (citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). Thus, the Board finds the Veteran’s lay statements regarding whether his hiatal hernia pre-existed service do not rebut the presumption of soundness. The Board notes that several VA medical opinions were obtained as to whether the Veteran’s hiatal hernia pre-existed service, however, these opinions were not clear and appear to be based solely on the Veteran’s statements. For example, the August 2011 VA opinion states that the Veteran reported during the VA examination that he was diagnosed with a hiatal hernia prior to his period of active duty. Similarly, the February 2017 VA opinion merely states the Veteran was diagnosed with a hiatal hernia before active duty service, with the rationale being that the Veteran “clearly stated that the hiatal hernia was found prior to service.” More recently, in August 2020, the VA examiner simply stated that the Veteran was diagnosed with a hiatal hernia in 1989 before active service, with no further rationale. In light of the circumstances of this case, the Board finds that this evidence does not rise to the level of clear and unmistakable evidence to rebut the presumption of soundness as to the pre-service existence of a hiatal hernia. As to an in-service event, the Veteran asserted during the August 2011 VA examination that his symptoms started in approximately 1989, and if he went more than four hours fasting, he developed epigastric pain and heartburn. In a February 2017 VA examination, the Veteran reported that the symptoms of reflux and epigastric burning continued since service. The Board notes that symptoms of pain and epigastric burning are capable of lay observation. The Board resolves all reasonable doubt in his favor and find that the Veteran experienced symptoms of epigastric pain and burning during service. Of note, the Veteran is currently service connected for gastroesophageal reflux disease (GERD), as secondary to medication taken for his service-connected disabilities. See April 2019 rating decision. In an October 2020 VA opinion, the examiner explained that a hiatal hernia is a bulge of the upper part of the stomach through the large muscle that separates the abdomen and the diaphragm, which causes the stomach to push up through the hiatus and into the chest. The examiner noted that this can cause heartburn and other symptoms of gastroesophageal reflux disease. There have been four attempts to obtain an adequate VA medical opinion for this issue. The Board finds that the evidence of record does not satisfactorily prove or disprove that the Veteran’s hiatal hernia had an onset during or is etiologically related to symptomatology noted in service or in-service exposure to environmental hazards. The Board declines to remand this appeal for a third time to obtain a fifth VA medical opinion. The Court of Appeals for Veterans Claims reiterated in Wise that “[b]y requiring only an ‘approximate balance of positive and negative evidence’ to prove any issue material to a claim for Veterans benefits, 38 U.S.C. § 5107 (b), the nation, ‘in recognition of our debt to our Veterans,’ has ‘taken upon itself the risk of error’ in awarding such benefits.” Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) (citing Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990)). The Board finds that reasonable doubt should be resolved in favor of the Veteran. Accordingly, reasonable doubt is resolved in favor of the Veteran and service connection for a hiatal hernia is warranted. 7. Entitlement to service connection for PTSD. The Veteran seeks entitlement to service connection for PTSD. See, e.g., March 2011 notice of disagreement. Importantly, the Veteran’s appeal for entitlement to service connection for an acquired psychiatric disorder was partially granted in an October 2020 rating decision, at which time service connection for an Axis I diagnosis of an insomnia disorder, as secondary to the Veteran’s service-connected lumbar spine disability, was established. As such, the issue on appeal has been limited to entitlement to service connection for PTSD. The Veteran asserts he has PTSD as a result of his time in service. Unfortunately, the preponderance of evidence indicates the Veteran does not have a post-service diagnosis of PTSD. The Board recognizes that a “clear” diagnosis of PTSD is not required. Rather, a diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125 (a), which simply mandates that, for VA purposes, all mental disorder diagnoses must conform to the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM). See 38 C.F.R. § 3.304 (f). Post-service records include private psychiatric treatment records. Unfortunately, many of the private treatment records are not legible; however, from the records located in the claims file, it does not appear that the private psychiatrist has diagnosed the Veteran with PTSD at any time during the appeal period. Furthermore, the Veteran was afforded several VA examinations, wherein it was noted that he did not meet the criteria for a diagnosis of PTSD. See, e.g., March 2013 VA examination; February 2017 VA examination; August 2020 VA examination. The Board recognizes the fact that the Veteran has sought treatment for what he claims is PTSD and that he has been prescribed medication for his psychiatric symptoms; however, the record does not contain a diagnosis of PTSD in accordance with 38 C.F.R. § 4.125 (a) and, therefore, service connection for PTSD is not warranted. The Veteran is competent to report his current symptoms, but his reports must be weighed against the medical evidence of record. See Grover v. West, 12 Vet. App. 109, 112 (1999); Jandreau, supra. To the extent that the Veteran has indicated that he currently has PTSD, the medical evidence showing an absence of such a disability is of greater probative weight than the Veteran’s reports made during the course of his claim for VA benefits. Further, as the question of causation extends beyond an immediately observable cause-and-effect relationship, he is not competent to render a diagnosis or address etiology in the present case. Although lay persons are competent to provide opinions on some medical issues, see, e.g., Kahana, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, whether the Veteran currently has PTSD falls outside the realm of common knowledge of a lay person. Additionally, although the Veteran has some medical knowledge as evidenced by being a medical specialist during service, he does not have the specialized psychiatric training or credentials to provide a competent opinion as to a psychiatric diagnosis or the onset date of such diagnosis. Consequently, his statements as to a current diagnosis of PTSD that is related to his service are not probative. Finally, the Board notes the Veteran’s symptoms have been attributed to an Axis I diagnosis of an insomnia disorder, for which he is currently service connected. The Board finds that the most probative evidence consists of the medical records. “Congress specifically limits entitlement to a service-connected disease or injury where such cases have resulted in a disability...in the absence of a proof of present disability there can be no claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The claim must be denied. In the absence of a diagnosis, the other elements of service connection for this claim need not be addressed. As a preponderance of the evidence is against a finding that the Veteran has a diagnosis of PTSD that conforms to diagnostic criteria, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). In sum, because post-service records do not indicate that the Veteran has a current diagnosis of PTSD in accordance with 38 C.F.R. § 4.125, the Board finds that the evidence is against a grant of service connection for this disorder. REASONS FOR REMAND 8. Entitlement to a TDIU is remanded. As a result of this decision, the Veteran has been granted entitlement to service connection for multiple disabilities. The AOJ must assign disability ratings in the first instance; such assignment may impact whether the Veteran satisfies the schedular requirements for a TDIU rating as set forth in 38 C.F.R. § 4.16 (a). Thus, a decision by the Board on the Veteran’s TDIU claim would be premature. The matters are REMANDED for the following action: Assign disability ratings and effective dates for the Veteran’s bilateral shoulder disability, cervical spine disability, bilateral ankle disability, bilateral knee disability, bilateral hip disability, and hiatal hernia; readjudicate the Veteran’s claim for entitlement to a TDIU. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Andersen, 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.