Citation Nr: 21061971 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 16-10 526 DATE: October 6, 2021 ORDER Service connection for degenerative joint disease of the right foot is granted. Service connection for residuals of right wrist shrapnel wound is granted. From April 29, 2010, entitlement to a rating of 10 percent, but no greater, for right forearm shell fragment wound is granted. Entitlement to an initial compensable rating for right chest shrapnel wound is denied. Entitlement to a total disability rating due to individual unemployability is granted. REMANDED Service connection for left foot arthritis, to include as secondary to fragment and shrapnel wounds, is remanded. Service connection for right hand arthritis, to include as secondary to fragment and shrapnel wounds, is remanded. Service connection for left hand arthritis, to include as secondary to fragment and shrapnel wounds, is remanded. Service connection for right knee arthritis, to include as secondary to fragment and shrapnel wounds, is remanded. Service connection for left knee arthritis, to include as secondary to fragment and shrapnel wounds, is remanded. Service connection for an arthritis disorder other than of the feet, hands, and knees, to include as secondary to fragment and shrapnel wounds, is remanded. Service connection for right lower extremity radiculopathy, to include as secondary to low back strain, is remanded. Service connection for a right face disorder characterized by tingling, pain, and numbness, to include as secondary to fragment and shrapnel wounds, is remanded. Service connection for a non-arthritis disorder of the right side of the body characterized by neurological symptoms, other than right lower extremity radiculopathy, residuals of right wrist shrapnel wound, right forearm shell fragment wound, right chest shrapnel wound, and right face disorder characterized by numbness and tingling, to include as secondary to fragment and shrapnel wounds, is remanded. FINDINGS OF FACT 1. The Veteran's degenerative joint disease of the right foot began during active service. 2. The Veteran's residuals of right wrist shrapnel wound began during active service. 3. From April 29, 2010, the Veteran's right forearm shell fragment wound is characterized by painful motion. 4. The Veteran's right chest shrapnel wound is not characterized by painful scars and covers an area of less than 144 square inches. 5. The Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability. CONCLUSIONS OF LAW 1. The criteria for service connection for degenerative joint disease of the right foot have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for right wrist shrapnel wound have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 3. From April 29, 2010, the criteria for a disability rating of 10 percent, but no greater, for right forearm shell fragment wound have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.14.14, 4.73, Diagnostic Code 5307. 4. The criteria for an initial compensable disability rating for right chest shrapnel wound have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.14.14, 4.118, Diagnostic Code 7802. 5. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1967 to March 1969, including service in the Republic of Vietnam. He was awarded the Purple Heart Medal. The Veteran died in January 2019. A May 2020 letter reflects that the Appellant has been accepted as the Veteran's substitute. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision. In December 2018, the Veteran withdrew his prior request for a hearing. This matter was remanded in January 2021. One of the remand instructions was to send the Appellant a VA 21-4142 identifying any outstanding treatment records. In April 2021, the Appellant indicated that all of the Veteran's records have been sent in. In January 2019, the Veteran submitted a VA 21-2680 form, alleging the need for aid and attendance. That form lists metastatic cancer, lactic acidosis, acute kidney injury, and malignant cachexia as the disorders underlying the need for special monthly compensation. This form does not list any of the disorders for which a claim for an increased rating is on appeal. The record does not otherwise reflect that the Veteran is in need of aid and attendance due to any of the disorders at issue in this appeal. For these reasons, the Board will not at this time adjudicate a claim of entitlement to special monthly compensation. In May 2021, the RO granted service connection for the Veteran's back disorder. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). If a veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). Every reasonable doubt is to be resolved in the veteran's favor and is rebuttable only by clear and convincing evidence. 38 U.S.C. § 1154(b). Furthermore, not only is the combat injury presumed, but so is the disability due to the in-service combat injury. Reeves v. Shinseki, 682 F.3d 988, 99899 (Fed. Cir. 2012). However, there must be the evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). 1. Service connection for degenerative joint disease of the right foot These elements are met for the Veteran's right foot disorder. The first element is met, in that the January 2011 VA foot examination indicates "DJD of the right foot per imaging." The second element is met, in that in a January 1968 service treatment record, the Veteran reports "loss of sensation of [right] foot for 3 days." The Board finds that service connection for degenerative joint disease of the right foot is warranted. There is a current right foot disorder and service treatment records corroborate the existence of in-service right foot problems. Resolving doubt in the Veteran's favor, the Board finds that the Veteran's degenerative joint disease of the right foot had its onset in service. 38 C.F.R. § 3.303(a); Flynn v. Brown, 6 Vet. App. 500, 503 (1994) (noting that "the element of cause and effect has been totally by-passed in favor of a simple temporal relationship between the incurrence of the disability and the period of active duty"). Service connection is warranted for degenerative joint disease of the right foot. 2. Service connection for residuals of right wrist shrapnel wound The Veteran argues that his right wrist problems are the result of the in-service shrapnel injury for which he was awarded a Purple Heart. The first element is met, in that a July 2010 VA examination describes "constant pain in the entrance wound site which is in the flexor musculature of the wrist just proximal to the ulnocarpal joints." Further, a March 2021 VA wrist opinion indicates that because of this wrist disorder "the Veteran may not have been able to tolerate activities requiring prolonged or excessive repetitive wrist motions such as typing, lifting, or turning wrenches." In light of the existence of right wrist pain resulting in functional loss, the Board finds that the first element of service connection is met. See Saunders v. Wilkie, 886 F.3d 1356, 136768 (Fed. Cir. 2018) ("To establish the presence of a disability, a veteran will need to show that [their] pain reaches the level of a functional impairment of earning capacity."). The second element is met, in that the Veteran argues that this disorder is the result of an in-service shrapnel wound, and his medical records corroborate this fact. An in-service shrapnel wound resulting in pain and functional loss is consistent with the circumstances, conditions, or hardships of the Veteran's combat service. As such, VA must presume the occurrence of the in-service injury. See 38 U.S.C. § 1154(b). The Board finds that the evidence is not sufficient to rebut the presumption that the Veteran's right wrist disorder became manifest during combat service. Since the evidence indicates that the Veteran's right wrist disorder had its onset during service, the Veteran is entitled to service connection for residuals of right wrist shrapnel wound. Increased Rating 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 percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to consider all regulations that are potentially applicable through the assertions and issues raised in the record. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). For painful motion with any form of arthritis, the Veteran is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The same is true for painful motion in non-arthritis contexts when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Right Forearm Shell Fragment Wound From March 22, 1969, service connection is warranted for right forearm shell fragment wound at an initial rating of 10 percent. From December 1, 1978, the Veteran is rated at 0 percent. Both rating are under Diagnostic Code 5307. On April 29, 2010, the Veteran filed a claim for an increased rating. Because the claim is a non-initial claim, the Board will consider evidence of symptomatology from one year prior to when the claim was filed. 38 C.F.R. § 3.400(o). See A.B. v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a claim remains in controversy where less than the maximum available benefit is awarded unless the Veteran expresses an intent to limit the appeal to a specific disability rating). If an increase in severity of disease is ascertainable prior to a year before the filing date, the effective date shall be the date that the increase in severity is discernible. See Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010). Diagnostic Code 5307 provides the rating criteria for evaluating Muscle Group VII. 38 C.F.R. § 4.73. The function of that muscle is flexion of the wrist and fingers. Id. Group VII muscles include those arising from internal condyle of humerus: Flexors of the carpus and long flexors of fingers and thumb; pronator. Id. For a slight disability, a 0 percent rating is provided for the major and minor limbs. Id. For a moderate disability, a 10 percent rating is provided for the major and minor limbs. Id. For a moderately severe disability, a 20 percent rating is provided for the minor limb and a 30 percent rating is provided for the major limb. Id. For a severe disability, a 30 percent rating is provided for the minor limb and a 40 percent disability is provided for the major limb. Id. Effective February 7, 2021, ratings of slight, moderate, moderately severe, or severe for diagnostic codes 5301 through 5323 will be determined based upon the criteria contained in § 4.56. 38 C.F.R. § 4.71a (Note 2). In evaluating muscle groups, an open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56. A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. Id. For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. Id. Under diagnostic codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe. Id. For a slight disability of muscles, regulations provide examples of type of injury, history and complaint, and objective findings. 38 C.F.R. § 4.56(d)(1). Type of injury is simple wound of muscle without debridement or infection. Id. History and complaint include service department record of superficial wound with brief treatment and return to duty; healing with good functional results; and no cardinal signs or symptoms of muscle disability as defined in § 4.56(c). Id. Objective findings include minimal scar; no evidence of fascial defect, atrophy, or impaired tonus; and no impairment of function or metallic fragments retained in muscle tissue. Id. For a moderate disability of muscles, regulations provide examples of type of injury, history and complaint, and objective findings. 38 C.F.R. § 4.56(d)(2). Type of injury is through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. Id. History and complaint include service department record or other evidence of in-service treatment for the wound, record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in § 4.56(c), particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Id. Objective findings include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue; also some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. Id. For a moderately severe disability of muscles, regulations provide examples of type of injury, history and complaint, and objective findings. 38 C.F.R. § 4.56(d)(3). Type of injury is through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. Id. History and complaint include service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in § 4.56(c) and, if present, evidence of inability to keep up with work requirements. Id. Objective findings include entrance and (if present) exit scars indicating track of missile through one or more muscle groups; indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side; and tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. Id. For a severe disability of muscles, regulations provide examples of type of injury, history and complaint, and objective findings. 38 C.F.R. § 4.56(d)(4). Type of injury is through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. Id. History and complaint include service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in § 4.56(c), worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Id. Objective findings include ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track; palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area; muscles swell and harden abnormally in contraction; and tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. Id. Further, if present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) Visible or measurable atrophy; (E) Adaptive contraction of an opposing group of muscles; (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4)(iii). 3. From April 29, 2010, entitlement to a rating of 10 percent, but no greater, for right forearm shell fragment wound is granted From April 29, 2010, the evidence supports a rating of 10 percent for right forearm shell fragment wound. In an April 2010 statement, the Veteran describes tingling in his right arm with "constant bouts of pain and numbness." In a July 2010 VA examination, the Veteran describes constant pain with tingling and numbness. For the right wrist, there is full range of motion and normal muscle strength. In a January 2011 VA examination, the Veteran describes "numbness spread through his low extremities to the right side of body including his right forearm." In a January 2011 VA examination, the Veteran "states that his right arm becomes numb and tingling at times, but denies pain in the right arm or limitation of motion." The examiner further notes "no objective evidence of abnormalities" and that there are "No Significant Effects" on "usual occupation." A December 2012 VA general exam indicates that the Veteran's right forearm disorder "should not prevent him from gainful employment." In a December 2012 statement, the Veteran describes a sensation of "things crawling all over [him] ... like having common pins stuck into your body ...." A June 2021 VA medical opinion concludes that "[t]here is a lack of sufficient objective medical evidence noted in the available medical records to support or confirm a conclusion that there were cardinal signs and symptoms of a muscle disability" for the Veteran's right forearm. This is because the Veteran's medical records do not "mention of loss of power, weakness, lowered threshold of fatigue, fatigue pain, impairment of coordination, and uncertainty of movement due to or the result of the service-connected shell fragment wound of the right forearm." The evidence consistently indicates right forearm pain and numbness. Giving the Veteran the benefit of the doubt, the Board finds that this evidence supports a rating of 10 percent under Burton from April 29, 2010. However, the also evidence consistently indicates that the Veteran's forearm pain does not impact his ability to work or result in significant functional loss. Further, while there are consistent reports of pain and numbness, there are no consistent complaints of the cardinal signs of muscle injury. For these reasons, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent. Right Chest Shrapnel Wound On January 25, 2010, the Veteran filed a claim of service connection for right chest shrapnel wound. In August 2011, the RO granted this claim at an initial noncompensable rating under Diagnostic Code 7802 from January 25, 2010. The Veteran timely appealed. Because the claim is an initial claim, the Board will consider evidence of symptomatology from the date that the claim was filed. 38 C.F.R. § 3.400(o). Effective August 13, 2018, the schedule of ratings for the skin was amended. 83 Fed. Reg. 32664 (July 13, 2018) (codified at 38 C.F.R. § 4.118). Since the Veteran's claim was pending prior to August 13, 2018 and was filed on or after October 23, 2008, the Board will be consider both the new schedule and the prior schedule that went into effect on October 23, 2008. Whatever schedule is more favorable to the Veteran will be applied. Diagnostic Code 7802 Effective October 23, 2008, Diagnostic Code 7802 provides compensation for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118. A 10 percent rating is provided for area or areas of 144 square inches (929 square centimeters) or greater. Id. Note (1) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Note (2) provides that if multiple qualifying scars are present, or if a single qualifying scar affects more than one extremity, or a single qualifying scar affects one or more extremities and either the anterior portion or posterior portion of the trunk, or both, or a single qualifying scar affects both the anterior portion and the posterior portion of the trunk, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity, assign a separate evaluation based on the total area of the qualifying scars that affect the anterior portion of the trunk, and assign a separate evaluation based on the total area of the qualifying scars that affect the posterior portion of the trunk. 38 C.F.R. § 4.118. The midaxillary line on each side separates the anterior and posterior portions of the trunk. Id. Combine the separate evaluations under § 4.25. Id. Qualifying scars are scars that are nonlinear, superficial, and are not located on the head, face, or neck. Id. Effective August 13, 2018, Diagnostic Code 7802 provides compensation for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. The recent amendments changed the Notes associated with Diagnostic Code 7802 but did not change the rating criteria. Note (1) now states that the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. 38 C.F.R. § 4.118. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2) now states that a separate evaluation may be assigned for each affected zone of the body under Diagnostic Code 7802 if there are multiple scars, or a single scar, affecting multiple zones of the body. 38 C.F.R. § 4.118. Under such circumstances, separate evaluations are to be combined under § 4.25. Id. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under Diagnostic Code 7802. Id. Diagnostic Code 7804 Effective October 23, 2008, Diagnostic Code 7804 provides compensation for painful or unstable scars. 38 C.F.R. § 4.118. A 10 percent rating is provided for one or two scars that are unstable or painful. Id. A 20 percent rating is provided for three or four scars that are unstable or painful. Id. A 30 percent rating is provided for five or more scars that are unstable or painful. Id. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118. Note (2) states that if one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is based on the total number of unstable or painful scars. Id. Note (3) states that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under Diagnostic Code 7804, when applicable. Id. No changes to Diagnostic Code 7804 were made by the amendments that went into effect on August 13, 2018. 4. Entitlement to an initial compensable rating for right chest shrapnel wound is denied The preponderance of the evidence is against an initial compensable rating. In a January 2010 statement, the Veteran describes receiving shrapnel in his right chest area as a result of an in-service shrapnel wound. In May 2010, the Veteran was granted service connection for a chest disorder based on "metallic dust fragments seen on chest x-ray" as a result of his in-service injury. The January 2011 and December 2012 VA scars examinations references right arm scars but not chest scars. A January 2019 private radiology record notes "[s]mall metallic fragments overlying the lower right chest that are probably related to an old gunshot wound." Neither the Veteran's lay statements nor his medical records specifically reference pain or functional loss associated with the right chest shrapnel wound. Further, the two scar examinations do not specifically reference any scars associated with this injury. It follows that any scars must be very minor, covering an area far less than 144 square inches. There is also no evidence that the Veteran used any treatments to alleviate any discomfort that was specific to his chest wound. In light of this evidence, the Board finds that the preponderance of the evidence is against an initial compensable rating for right chest shrapnel wounds. TDIU An award of TDIU "does not require proving 100 percent unemployability." Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). Rather, an award of TDIU requires that the claimant show an inability "to secure and follow a substantially gainful occupation by reason of service-connected disabilities." 38 C.F.R. § 4.16(b). When making this determination, "the central inquiry is whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Pederson v. McDonald, 27 Vet. App. 276, 286 (2015) (internal citations and quotations omitted). Additionally, the Board "must take into account the individual veteran's education, training, and work history" but "may not consider [nonservice]-connected disabilities or advancing age." Id. (internal citations omitted). The phrase "substantially gainful employment" has an economic component and a non-economic component. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). "The economic component simply 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." Id. The noneconomic component goes to the veteran's individualized ability to secure and follow substantially gainful employment. Ray, 31 Vet. App. at 73. Attention must be given to the following: the veteran's history, education, skill, and training; whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy). Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, and auditory and visual limitations; whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity. Id. These factors do not constitute a checklist; rather, "discussion of any factor is only necessary if the evidence raises it." Id. When entitlement to a TDIU is raised during the adjudicatory process of the underlying disability, it is part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). A claim for a TDIU is a claim for an increased rating. Dalton v. Nicholson, 21 Vet. App. 23, 3132 (2007). The general rule with respect to the effective date of an award of increased compensation is that the effective date of award "shall not be earlier than the date of receipt of the application thereof." 38 U.S.C. § § 5110(a). This statutory provision is implemented by regulation that provides that the effective date for an award of increased compensation will be the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). An exception to that rule regarding increased ratings applies to circumstances where the evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. If an increase in disability occurred one year prior to the claim, the increase is effective as of the date the increase is "factually ascertainable." If the increase occurred more than one year prior to the claim, the increase is effective the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o); Dalton, 21 Vet. App. at 3132. VA regulations indicate that when a veteran's schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned: 1) if there is only one disability, this disability shall be ratable at 60 percent or more; and 2) if there are two or more disabilities, at least one disability shall be ratable at 40 percent or more, and there must be sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, constitutes a single disability under § 4.16(a). The same is true for disabilities resulting from common etiology or a single accident. TDIU Evidence The Veteran filed claims for TDIU on June 22, 2010, and July 20, 2012. This was during the pendency of the Veteran's claim of an increased rating for a right forearm disorder, filed on April 29, 2010. The Board will consider evidence within the one-year period preceding the date of receipt of this claim. See 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o); Dalton, 21 Vet. App. at 3132. From April 29, 2010, to July 21, 2010, service connection has been awarded for PTSD at 50 percent, dermatitis and tinea versicolor at 30 percent, right forearm shell fragment wound at 10 percent, keloids at 0 percent, and right chest shrapnel wound at 0 percent with a combined rating of 70 percent. For this time period, the Veteran meets the percentage rating standards to be considered for individual unemployability under 38 C.F.R. § 4.16(a). From July 22, 2010, service connection has been awarded for PTSD at 50 percent, dermatitis and tinea versicolor at 30 percent, right forearm shell fragment wound at 10 percent, low back strain at 10 percent, keloids at 0 percent, and right chest shrapnel wound at 0 percent with a combined rating of 70 percent. For this time period, the Veteran meets the percentage rating standards to be considered for individual unemployability under 38 C.F.R. § 4.16(a). In a January 2010 VA examination, the Veteran states that he cannot work because of "physical conditions" but not because of any mental disorder. In an April 2010 VA examination, the Veteran describes "flares to [pain] levels of 8/10 when he uses his right wrist for usual activities of daily living including buttoning and unbuttoning." Further, "he cannot do anything strenuous with the right hand." The examiner indicates that the Veteran is right-handed. In a June 2010 TDIU application, the Veteran indicates that he last worked full-time in 1979. In a January 2011 VA scars examination, the Veteran indicates that "he retired because of the PTSD and shrapnel and rash." A January 2011 VA PTSD examination indicates that the Veteran's usual occupation is construction, which he is prevented from participating in due to "[p]hysical conditions" but not the effects of his mental disorder. In a January 2011 VA examination, the Veteran "states that his right arm becomes numb and tingling at times, but denies pain in the right arm or limitation of motion." The examiner further notes "no objective evidence of abnormalities" and that there are "No Significant Effects" on "usual occupation." An April 2011 VA eye examination lists the Veteran's "usual occupation" as "construction worker" and indicates that he is "[u]nable to find work" due to "vision & leg problems." In a July 2012 statement, the Veteran describes having to use a cane due to loss of balance. The Veteran's July 2012 TDIU application lists his usual occupation as "laborer." he last worked in April 2000, and last worked full-time as a laborer in June 1996, where he earned up to $1,000 per month. The most he ever earned in a year was $20,000. The Veteran has three years of college. A December 2012 VA PTSD examination indicates that the Veteran "used to work in computer operations during the 80s" but has been unemployed since that time. His examiner later states that he "is not employable due to PTSD" but that "PTSD should not preclude light duty or sedentary employment." In a June 2013 statement, the Veteran describes being terminated from several jobs "due to an unbearable and continuing itchy skin condition ...." A March 2021 VA medical opinion indicates that because of his back disorder "[t]he Veteran may not have tolerated activities that required heavy, repetitive, or excessive lifting; he may not have tolerated activities that required excessive or prolonged walking, standing, or sitting; he may not have tolerated activities that excessive bending." A separate March 2021 VA medical opinion indicates that because of his wrist disorder "the Veteran may not have been able to tolerate activities requiring prolonged or excessive repetitive wrist motions such as typing, lifting, or turning wrenches." TDIU Analysis 5. Entitlement to a total disability rating due to individual unemployability The Veteran's recorded work history consists entirely of manual labor. He seems to have worked largely in construction. Despite his singular reference to computer work in the 1980s, he does not have education or significant office experience that would support substantially gainful occupation in a sedentary position. The Board finds that the Veteran's service-connected disorders alone render him physically unable to engage in substantially gainful occupation in a field requiring physical labor. He is right-handed and his wrist disorder precludes repetitive exertion on his dominant side. His back disorder and right ankle disorders further prohibit extended periods of exertion. Additional functional limitations appear to arise from his service-connected dermatitis and tinea versicolor. In light of these functional limitations, the Board finds that the Veteran's service-connected disorders alone render him physically unable to engage in a substantially gainful employment in a field requiring physical labor. The PTSD examiner notes that the Veteran's PTSD precludes sedentary work, but not non-sedentary work. However, the Veteran has no significant training or experience that would allow him to partake in substantially gainful employment in a sedentary field. It follows that the Veteran's PTSD render mentally unable to work. Taken together, the Board finds that the Veteran's service-connected disorders alone render him physically and mentally unable to engage in substantially gainful employment in a field requiring physical labor. It is undisputed that the Veteran has not generated any employment-related income for the period on appeal. For these reasons, entitlement to TDIU is warranted. REASONS FOR REMAND 1. Service connection left foot arthritis, to include as secondary to fragment and shrapnel wounds, is remanded. 2. Service connection right hand arthritis, to include as secondary to fragment and shrapnel wounds, is remanded. 3. Service connection left hand arthritis, to include as secondary to fragment and shrapnel wounds, is remanded. 4. Service connection for right knee arthritis, to include as secondary to fragment and shrapnel wounds, is remanded. 5. Service connection for left knee arthritis, to include as secondary to fragment and shrapnel wounds, is remanded. 6. Service connection for an arthritis disorder other than of the feet, hands, and knees, to include as secondary to fragment and shrapnel wounds, is remanded. In a July 2010 VA 21-4138, the RO recognized a claim of service connection for arthritis. In reviewing the Veteran's medical records, the Board has identified references to arthritis in the Veteran's hands, knees, and right foot. Specifically, a September 2011 VA medical record indicates "arthritis in hands flare, feet, legs." A January 2012 VA medical record indicates arthritis in the Veteran's hands. A January 2019 private radiology record (received 1/29/20, page 16 of 41) indicates right knee degenerative joint disease. As explained, the Board has granted service connection for degenerative joint disease of the right foot. An April 1967 service treatment record states that the Veteran "twisted [left] ankle while running last night now has ... swelling and tenderness." The Board has recharacterized the issues on appeal accordingly. As the RO has not obtained a specific opinion addressing all identified arthritis disorders, a remand is required. 7. Service connection for right lower extremity radiculopathy, to include as secondary to low back strain, is remanded. A June 2021 VA medical opinions concludes that the Veteran's radiculopathy is less likely than not related to service. The rationale is that the radiculopathy is the result of degenerative disc disease (for which service connection has not been awarded), not the lumbar strain disorder for which the examiner states that service connection was mistakenly awarded. Per the examiner, since lumbar strain is a muscle disease, it does not impact nerves so as to cause radiculopathy. Rather, radiculopathy is the result of degenerative disc disease, for which service connection has not been awarded. For secondary service connection, a VA medical opinion should not combine causation and aggravation; separate findings and rationale should be provided. Atencio v. O'Rourke, 30 Vet. App. 74, 8991 (2018). As the June 2021 VA medical opinion does not contain separate bases for causation and aggravation, a new medical opinion is required. 8. Service connection for a right face disorder characterized by tingling, pain, and numbness, to include as secondary to fragment and shrapnel wounds, is remanded. In August 2011, the RO denied service connection for this disorder on the basis that there was no current disability. This opinion does not address the Veteran's lay reports of symptoms. For example, the July 2010 VA examination reports "tingling, pain, and numbness" in the Veteran's face. In a January 2011 VA examination, the Veteran describes paresthesias "from the right toe involving the whole right side to the top of his head." Also, a medical opinion was ever obtained. A remand is therefore required. 9. Service connection for a non-arthritis disorder of the right side of the body characterized by numbness and tingling other than right lower extremity radiculopathy, residuals of right wrist shrapnel wound, forearm shell fragment wound, right chest shrapnel wound, and right face disorder characterized by numbness and tingling, to include as secondary to fragment and shrapnel wounds, is remanded. In August 2011, the RO denied service connection for this disorder on the basis that there was no current disability. This opinion does not address the Veteran's lay reports of symptoms. For example, a July 2010 VA examination describes "numbness in the entirety of the right lower extremity" that "does not have a physiological cause." In a January 2011 VA examination, the Veteran describes "numbness spread through his low extremities to the right side of body including his right forearm." In a January 2011 VA examination, the Veteran describes paresthesias "from the right toe involving the whole right side to the top of his head." In a December 2012 statement, the Veteran describes a sensation of "things crawling all over [him] like having common pins stuck into your body ...."Also, a medical opinion was ever obtained. A remand is therefore required. The matters are REMANDED for the following action: 1. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: (a.) Whether the Veteran had left foot arthritis. (b.) Whether it is at least as likely as not that any left foot arthritis was incurred in the Veteran's service, including but not limited to as a result of his in-service shrapnel injury. (c.) Whether the Veteran has any current or left foot arthritis that is proximately due to the Veteran's fragment and shrapnel wounds. (d.) Whether the Veteran has any left foot arthritis that was aggravated by the Veteran's fragment and shrapnel wounds. This must be addressed in a separate opinion from the "proximately due to" opinion. In rendering these opinions, the examiner should consider the September 2011 VA medical record indicating "arthritis in hands flare, feet, legs." The examiner should also consider the April 1967 service treatment record indicating that the Veteran "twisted [left] ankle while running last night - now has ... swelling and tenderness." The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. 2. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: (a.) Whether the Veteran had hand arthritis. (b.) Whether it is at least as likely as not that any hand arthritis was incurred in the Veteran's service, including but not limited to as a result of his in-service shrapnel injury. (c.) Whether the Veteran has any hand arthritis that is proximately due to the Veteran's fragment and shrapnel wounds. (d.) Whether the Veteran had hand arthritis that was aggravated by the Veteran's fragment and shrapnel wounds. This must be addressed in a separate opinion from the "proximately due to" opinion. In rendering these opinions, the examiner should consider the September 2011 VA medical record indicating "arthritis in hands flare, feet, legs." The examiner should also address the January 2012 VA medical record indicating arthritis in the Veteran's hands. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. 3. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: (a.) Whether the Veteran has any knee arthritis. (b.) Whether it is at least as likely as not that any knee arthritis was incurred in the Veteran's service, including but not limited to as a result of his in-service fragment and shrapnel injury. (c.) Whether the Veteran had knee arthritis that is proximately due to the Veteran's fragment and shrapnel wounds. (d.) Whether the Veteran had knee arthritis that was aggravated by the Veteran's fragment and shrapnel wounds. This must be addressed in a separate opinion from the "proximately due to" opinion. In rendering these opinions, the examiner should consider the September 2011 VA medical record indicating "arthritis in hands flare, feet, legs." The examiner should also address the January 2019 private radiology record (received 1/29/20, page 16 of 41) indicating right knee degenerative joint disease. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. 4. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: (a.) Whether the Veteran had arthritis disorder other than of the feet, hands, and knees. (b.) Whether it is at least as likely as not that any arthritis disorder other than of the feet, hands, and knees was incurred in the Veteran's service, including but not limited to as a result of his in-service shrapnel injury. (c.) Whether the Veteran had arthritis disorder other than of the feet, hands, and knees that is proximately due to the Veteran's fragment and shrapnel wounds. (d.) Whether the Veteran had arthritis disorder other than of the feet, hands, and knees that was aggravated by the Veteran's fragment and shrapnel wounds. This must be addressed in a separate opinion from the "proximately due to" opinion. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. 5. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: (a.) Whether the Veteran had right lower extremity radiculopathy that is proximately due to the Veteran's low back strain. (b.) Whether the Veteran had right lower extremity radiculopathy that was aggravated by the Veteran's low back strain. This must be addressed in a separate opinion from the "proximately due to" opinion. The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. 6. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: (a.) Whether the Veteran had right face disorder characterized by tingling, pain, and numbness. (b.) Whether it is at least as likely as not that any right face disorder characterized by tingling, pain, and numbness was incurred in the Veteran's service, including but not limited to as a result of his in-service shrapnel injury. (c.) Whether the Veteran had right face disorder characterized by tingling, pain, and numbness that is proximately due to the Veteran's fragment and shrapnel wounds. (d.) Whether the Veteran had right face disorder characterized by tingling, pain, and numbness that was aggravated by the Veteran's fragment and shrapnel wounds. This must be addressed in a separate opinion from the "proximately due to" opinion. In rendering these opinions, the examiner should consider the July 2010 VA examination description of tingling, pain, and numbness in the Veteran's face. The examiner should also consider the January 2011 VA examination description of paresthesias "from the right toe involving the whole right side to the top of his head." The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. 7. After obtaining any additional records to the extent possible, an examiner should review the entire claims file and provide the following opinions: (a.) Whether the Veteran had non-arthritis disorder of the right side of the body characterized by neurological symptoms, other than right lower extremity radiculopathy, residuals of right wrist shrapnel wound, forearm shell fragment wound, right chest shrapnel wound, and right face disorder characterized by numbness and tingling. (b.) Whether it is at least as likely as not that any non-arthritis disorder of the right side of the body characterized by neurological symptoms, other than right lower extremity radiculopathy, residuals of right wrist shrapnel wound, forearm shell fragment wound, right chest shrapnel wound, and right face disorder characterized by numbness and tingling, was incurred in the Veteran's service, including but not limited to as a result of his in-service shrapnel injury. (c.) Whether the Veteran had non-arthritis disorder of the right side of the body characterized by neurological symptoms, other than right lower extremity radiculopathy, residuals of right wrist shrapnel wound, forearm shell fragment wound, right chest shrapnel wound, and right face disorder characterized by numbness and tingling, that is proximately due to the Veteran's fragment and shrapnel wounds. (d.) Whether the Veteran had non-arthritis disorder of the right side of the body characterized by neurological symptoms, other than right lower extremity radiculopathy, residuals of right wrist shrapnel wound, forearm shell fragment wound, right chest shrapnel wound, and right face disorder characterized by numbness and tingling, that was aggravated by the Veteran's fragment and shrapnel wounds. This must be addressed in a separate opinion from the "proximately due to" opinion. In rendering these opinions, the examiner should consider the July 2010 VA examination describing "numbness in the entirety of the right lower extremity" that "does not have a physiological cause." The examiner should also consider the January 2011 VA examination, in which the Veteran describes "numbness spread through his low extremities to the right side of body including his right forearm." The examiner should also consider the January 2011 VA examination, in which the Veteran describes paresthesias "from the right toe involving the whole right side to the top of his head." The examiner should also consider the December 2012 statement, in which the Veteran describes a sensation of "things crawling all over [him] like having common pins stuck into your body ...." The examiner should provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Cannon, Brian 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.