Citation Nr: 21063018 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 08-06 921A DATE: October 12, 2021 ORDER Entitlement to a rating in excess of 10 percent for residuals of an injury to the right leg (thigh) with arthritis of the right knee is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted from June 25, 2007. REMANDED Entitlement to service connection for erectile dysfunction, to include as secondary to a service-connected disability is remanded. Entitlement to a TDIU prior to June 25, 2007, on an extraschedular basis, is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's residuals of an injury to the right leg injury with arthritis of the right knee was manifested by limitation of flexion to no more than 45 degrees and limitation of extension to no more than 5 degrees. 2. From June 25, 2007, the Veteran's service-connected disabilities meet the schedular criteria for award of a TDIU, and the Veteran's service-connected disabilities preclude substantially gainful employment. CONCLUSION OF LAW 1. The criteria for a rating in excess of 10 percent for residuals of an injury to the right leg (thigh) with arthritis of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.171a, Diagnostic Code (Code) 5003-5010. 2. The criteria for an award of TDIU, for the period beginning June 25, 2007, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.25, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1961 to October 1963 with additional periods of unverified service. This case has been before the Board multiple times, most recently in January 2021 when it was remanded for additional developments. The Board finds there has been substantial compliance with the remand directives for the claims decided herein. Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating The Veteran seeks a higher rating for his service-connected residuals of an injury to the right leg (thigh) with arthritis of the right knee which is rated as 10 percent disabling under 38 C.F.R. § 4.71a Code 5003-5010. He filed his claim for an increased rating in May 2006. Disability ratings are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate Codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. See 38 C.F.R. § 4.45. These determinations are, if feasible, to be expressed in terms of the degree of additional loss-of-motion due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The right leg disability is rated as 10 percent disabling under Diagnostic Codes 5003-5010. Diagnostic Code 5010 directs that arthritis due to trauma is rated as arthritis, degenerative, under Diagnostic Code 5003. Under Code 5003, degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic code for the specific joint involved. Where the limitation of motion is noncompensable under the appropriate diagnostic code a (maximum) 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added, under Code 5003. 38 C.F.R. § 4.71a. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010, Note 1. In this case, the Veteran's right knee is involved. During the pendency of the Veteran's claim and appeal, the criteria for rating musculoskeletal disabilities were changed by an amendment to the rating schedule that became effective on February 7, 2021. 85 Fed. Reg. 76, 453 (November 30, 2020). The amendments provide that the Board should apply the criteria which are more favorable to the Veteran. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The February 2021 changes to the rating criteria for the knee pertain to Diagnostic Code 5257 (instability) and Diagnostic Code 5262 (impairment of the tibia and fibula). The rest of the rating criteria for the knee are unchanged. Under Code 5260, which contemplates limitation of leg flexion, a 0 percent rating is warranted for flexion limited to 60 degrees; a 10 percent rating is warranted for flexion limited to 45 degrees; a 20 percent rating is warranted for flexion limited to 30 degrees; and a 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Code 5260. Under Code 5261, which contemplates limitation of extension of the leg, a 0 percent rating is warranted for extension limited to 5 degrees; a 10 percent rating is warranted for extension limited to 10 degrees; a 20 percent rating is warranted for extension limited to 15 degrees; a 30 percent rating is warranted for extension limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Code 5261. Separate ratings may also be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). A veteran who has arthritis and instability of the knee may be rated separately under Codes 5003 and 5257. Evaluation of a knee disability under both of those Codes does not amount to pyramiding. However, a separate rating must be based on additional compensable level of disability. 38 C.F.R. § 4.14; VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63604 (1997); Esteban v. Brown, 6 Vet. App. 259 (1994). For VA compensation purposes, normal flexion of the knee is to 140 degrees, and normal extension is to zero degrees. 38 C.F.R. § 4.71a, Plate II. Code 5258 provides a 20 percent evaluation for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Code 5259 provides a 10 percent evaluation for removal of semilunar cartilage that is symptomatic. Under the older version of Code 5257, a 10 percent rating is available for slight recurrent subluxation or lateral instability. A 20 percent rating is assigned for moderate recurrent subluxation or lateral instability. A 30 percent rating is assigned for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Code 5257. On October 2006 VA examination, the Veteran reported he injured his right lower extremity while playing football during service and he has had persistent pain in his right knee area that had worsened over time. He reported intermittent pain with stiffness, rated on average of 5 to 10 out of 10 in intensity. His pain was aggravated by walking, standing, and bending. He reported he his right knee locked at times, and buckled, clicked, and popped at time. He also reported occasional right anterior thigh pain, usually occurring during weather changes. On physical examination there was no gross deformity, joint effusion, or joint line tenderness. Range of motion testing was 0 to 130 with pain at the end of range of motion. The Veteran was able to perform five repetitions with no additional loss of range of motion. There was no evidence of fatigue, weakness or lack of endurance. There was no evidence of ligamentous laxity. Gait was normal without assistive devices. On examination of his right thigh, there was no gross deformity, or tenderness to palpation. On April 2010 VA examination, the Veteran reported worsening right knee pain over time, which was intermittent and rated as 8 to 9 out of 10. He reported he did not have pain in his right thigh. He denied having swelling or clicking of his right knee, but noted that hit popped at times. On physical examination there was no gross deformity, joint effusion, or joint line tenderness. Range of motion was 0 to 110 degrees with no associated pain. Following three repetitive use testing range of motion remained the same with no pain. There was no evidence of fatigue, weakness, or lack of endurance. Negative anterior drawer and Lachman tests. His right thigh demonstrated no gross deformity and there was no tenderness to palpation. There was x-ray evidence of small to moderate joint effusion in the knee. At the November 2011 hearing, the Veteran testified that his right knee had gotten worse and he could not bend it like he used to. He also testified he had pain. On September 2014 VA examination, the Veteran reported having flare-ups of his right knee, and that he would not use his knee during flare-ups. On range of motion testing right knee flexion was 115 degrees and extension was to 0 degrees. There was no objective evidence of painful motion. Following three repetitive use testing range of motion remained the same with no pain. On muscle strength testing, right knee flexion was rated 5 out of 5 and right knee extension was rated as 4 out of 5. Joint stability testing was normal. The examiner opined that the Veteran's right leg disability impacted his ability to work as he could not lift or carry more than 50 pounds, stand for more than 30 minutes, walk for more than 30 minutes, and was unable to squat. On September 2017 VA examination the Veteran reported persistent pain in his right knee area which had worsened over time. He had intermittent pain with stiffness, rated on average as 5 out of 10. Pain was aggravated by walking, standing, and bending. He reported that at times it locked, buckled, clicked, and popped. He also reported occasional right anterior thigh pain, usually occurring during weather changes. He did not report having flare-ups of his leg disability. On range of motion testing right knee flexion was 135 degrees and extension was to 0 degrees. There was evidence of pain on both flexion and extension, but it did not result in functional loss. There was no evidence of pain with weight bearing, objective evidence of localized tenderness or pain on palpation of the joint or soft tissue. There was evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional functional loss or range of motion. Muscle strength testing was normal for flexion and extension. The examiner specifically noted the Veteran did not have ankylosis. On joint stability testing, there was no instability. The examiner noted that the Veteran did not use any assistive device as a normal mode of locomotion. The examiner opined that the Veteran's right leg disability did not impact in his ability to perform any occupational task. On December 2019 VA examination, the Veteran reported intermittent anterior right knee stiffness, worse with hyperflexion, lifting/carrying heavy objects especially upstairs, repeating going from sitting to standing, getting in and out of car, going up stairs, prolonged driving, and putting on socks in a standing position. He also reported occasional pain with these movements, but predominately stiffness. He reported having flare-ups of his right knee, and that he would not use his knee during flare-ups. On range of motion testing right knee flexion was 135 degrees and extension was to 0 degrees. There was no objective evidence of painful motion. The examiner noted that normal range of motion for the Veteran was not 140 degrees but about 125 degrees based on his age. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional functional loss or range of motion. On muscle strength testing, right knee flexion was rated 5 out of 5 and right knee extension was rated as 4 out of 5. Joint stability testing was normal. The examiner noted that the Veteran did not use any assistive device as a normal mode of locomotion. The examiner opined that the Veteran's right leg disability impacted his ability to work as he could not lift or carry more than 50 pounds, stand for more than 30 minutes, walk for more than 30 minutes, and was unable to squat. At the December 2020 hearing, the Veteran testified that his right thigh was sore and that he had a limp. On June 2021 VA examination, the Veteran reported that his right leg disability had worsened since onset and he had stiffness, especially with cold weather, and pain. The Veteran reported having flare-ups of his right leg disability occurring 3 to 4 times a month, lasting 2 to 3 days, and manifested by pain, swelling, and stiffness. Precipitating factors for flare-ups was overuse and walking for prolonged time, and it was alleviated by rest. He described that during flare-ups it was hard to sit, stand, and walk due to stiffness and pain. On range of motion testing on both active and passive motion right knee flexion was 128 degrees and extension was to 0 degrees. There was evidence of pain on both flexion and extension, on active and passive motion, but it did not result in functional loss. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional functional loss or range of motion. The examiner noted that the examination was not being conducted during a flare-up and that the evidence procured, including statement from the Veteran did not suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability during flare-ups. The examiner specifically noted there was no ankylosis, no recurrent subluxation or persistent instability, no ligament tear, or no recurrent patellar instability. The Veteran did not have and had not been diagnosed with recurrent patellar dislocation, shin splints, stress fractures, or any other tibial or fibular impairments. The examiner opined that the Veteran's right leg disability impacted his ability to perform any type of occupational task because the optimal work environment would not require prolonged walking or running and would allow for frequent position changes. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's residuals of an injury to the right leg injury with arthritis of the right knee. The Veteran's right leg disability is rated under the criteria for both degenerative and traumatic arthritis, which provides that the rating will be based upon the limitation of motion unde the specific joints involved, and a 10 percent rating is assigned when limitation of motion is noncompensable. Here, the Veteran's right knee is the involved joint and the Veteran is already in receipt of a 10 percent rating. As the Veteran has limitation of motion throughout the period on appeal in order for the Veteran to receive a rating higher than 10 percent, it must be based upon the criteria for limitation of motion provided for the knee rating criteria. 38 C.F.R. § 4.71a Code 5003. Based on the evidence of record, the Board concludes that an increased rating is not warranted based on limitation of flexion or extension at any point during the period on appeal. At worst, and with consideration of pain and flare-ups, his right knee flexion was to 115 degrees and right knee extension was to 0. Therefore, the Board finds that the criteria for a higher 20 percent rating under Code 5260, for limitation of flexion are not met or more closely approximated; flexion is not limited to 30 degrees, even with consideration of pain and flare-ups. The Board also finds that the criteria for a separate compensable rating under Code 5261, for limitation of extension, are not met. Extension has been normal throughout the appeal period. The currently assigned 10 percent rating under Code 5260 is consistent with 38 C.F.R. § 4.59, providing for a compensable rating for painful motion that does not meet the criteria for a minimum rating based on limitation of motion under Codes 5260 or 5260. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board has also considered whether a separate rating for instability is warranted, but concludes it is no as no instability was found on VA examinations and VA treatment and the Veteran did not report instability, during the period. In deciding the claim, the Board has also considered the Veteran's lay statements that his right leg disability was worse than currently evaluated. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which his disabilities are evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective complaints of increased symptomatology. Entitlement to TDIU At issue is whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Affording the Veteran the benefit of the doubt, the Board finds his service-connected disabilities render him unable to secure and follow substantially gainful employment from June 25, 2007. 38 C.F.R. § 4.16 (a). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341 (a). In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The Veteran's service-connected disabilities are mood disorder, rated as 10 percent from June 25, 2007, 30 percent from January 11, 2010, and 50 percent from May 7, 2012; bilateral hearing loss, 10 percent from September 1, 1967 and 40 percent from May 15, 2006; residuals of injury to the right leg (thigh) with arthritis of right knee, 10 percent from September 1, 1967; tinnitus 10 percent from December 2, 2012; tinea pedis/manis, 10 percent from May 15, 2006; back disability, 10 percent from June 25, 2007; left lumbar radiculopathy, 10 percent from June 25, 2007; right lumbar radiculopathy, s 10 percent from June 25, 2007; and hemorrhoids, noncompensable from March 3, 2010. The TDIU claim is pending from May 2006. The Veteran's combined disability rating is 60 percent from May 2006 and 70 percent from June 2007. The schedular criteria for TDIU are met from June 25, 2007, the first date he had one disability rated at 40 percent and a combined rating of 70 percent. Prior to that date, the service-connected disabilities that resulted in the combined 60 percent rating cannot be considered "one disability" for these purposes. 38 C.F.R. § 4.16 (a). The fact that a veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the Veteran, because of service-connected disability, is incapable of performing the physical and mental acts required by employment, not whether she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In making its determination, VA considers such factors as the extent of the service-connected disabilities, and employment and educational background. 38 C.F.R. §§ 4.16 (b), 4.19. Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose, 4 Vet. App. at 363. At a February 2008 initial psychiatric evaluation, the Veteran reported having severe depression and frustration due to his chronic medical conditions. He reported he was extremely afraid of falling because he did not think he would be able to get up with assistance. He reported that his hearing loss was particularly frustrating and described that he was not able to hear the sermon in church, and described situations in which he had to ask people to consistently repeat themselves in social conversation and when he used the telephone. The examiner noted the Veteran had entered service with a bachelor's degree, worked as a medic during service, and after his active duty service received a master's degree and a doctorate in education. His work history included public school teacher, football and track coach, college administrator, and human resources. He retired in 1998. The examiner did not characterize the level of occupational impairment. The Veteran reported his depression, skin disease, hearing loss, hematoma, arthritis, and lower back disabilities prevented him from securing or following any substantially gainful occupation. He reported he had last worked full time in 1998, when he became too disabled to work. He worked as a manager for training and development for a telephone company. He reported he had he had a Doctorate in Education. See VA Forms 21-8940, Application for TDIU, received in March and November 2010. On VA psychiatric examination in April 2010, the examiner noted that the Veteran was retired and was not currently working. The examiner opined that the Veteran's psychiatric symptoms would not prevent employment. The Veteran reported that he found it extremely difficult to engage in social conversations. He described that as a consequence of his hearing loss background noise is extremely uncomfortable. He also had difficulty on the telephone because he did not have the verbal cue to read lips. The examiner opined that the Veteran's psychiatric symptoms resulted in occupational and social impairment with occasional decreases in work efficiency and occasional difficulty in socialization as direct consequence of his mood swings including depressed mood with associated impaired sleep. At a November 2011 hearing, the Veteran testified that he believed he could not work due to his hearing. He testified that he last worked in 1998 and that he had been a teacher, a football coach, a corporate education director, and a college administrator. On July 2012 VA psychiatric examination, the Veteran's symptoms included depressed mood, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, irritability, and difficulty concentration. The examiner opined that the Veteran's psychiatric symptoms resulted in occupational and social impairment with reduced reliability and productivity. On September 2014 VA psychiatric examination, the examiner noted that the Veteran has a Ph. D. in education and worked in many aspects of education. He was also head of the corporate education program at AT&T. He last worked in 2000-2001 when he worked as a consultant for a program in health-related studies. The examiner found there was no obvious psychiatric signs of occupational impairment noted that would significantly impact his capacity for productive employment. The Veteran's symptoms included depressed mood, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships. The examiner opined that the Veteran's symptoms resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or; symptoms controlled by medication. On September 2014 VA knee examination, the examiner opined that the Veteran's right leg disability impacted his ability to work as he could not lift or carry more than 50 pounds, stand for more than 30 minutes, walk for more than 30 minutes, and was unable to squat. After an October 2014 VA hearing loss examination, the examiner opined that the Veteran's hearing loss impacted his ordinary conditions of daily life including ability to work because as the Veteran reported he could not hear his television, someone across the room, cannot hear in his car or his grandchildren. On functional impairment and unemployability, the examiner noted the Veteran may have experienced some difficulty communicating in noisy environments and sometimes on the phone, however, with the use of appropriate amplification and reasonable accommodations as specified in the American with Disability Act, the Veteran's hearing loss taken from this examination should not significantly affect vocational potential or limit participation in most work activities. Additionally, the examiner opined that the Veteran's tinnitus impacted his ordinary conditions of daily life, including the ability to work as it bothers him when his tinnitus acts up and gets mixed into everything else. On September 2017 VA knee examination the Veteran reported persistent pain in his right knee area which had worsened over time. The examiner opined that the Veteran's right leg disability did not impact in his ability to perform any occupational task. On September 2017 VA back examination, the examiner opined that the Veteran's back condition or peripheral nerve condition did not impact his ability to work. At the December 2020 hearing, the Veteran testified that his work history included teaching in public schools and colleges, coaching football and track, college administration, and corporate education. He testified that he believed his hearing would prevent him from doing those type of jobs because he could not hear with background noise. At a June 2021 VA knee examination, the Veteran reported that his right leg disability had worsened since onset and he had stiffness, especially with cold weather, and pain. After the examination, the examiner concluded that the Veteran's right leg disability impacted his ability to work and that the "optimal work environment would not require prolonged walking or running and would allow for frequent position changes." "Sedentary settings" were described as suitable. The ultimate question of whether a Veteran is capable of securing or following substantially gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013). The Board finds that the Veteran's service-connected disabilities precluded him from being able to maintain substantially gainful employment effective from June 25, 2007. His work history as a teacher, coach, administrator, and corporate educator involved extensive interacting and communicating with people. Throughout the period on appeal, the Veteran's service-connected hearing loss resulted in difficulty hearing and communicating with people on the telephone and in person. Additionally, as noted by the September 2014, December 2019, and June 2021 VA knee examines, the Veteran's right leg disability impacted his ability to stand and sit for long periods of time, and required him to change position frequently, all of which would be difficulty as a teacher or in an administrative position. Accordingly, and resolving any reasonable doubt in the Veteran's favor, the Board finds that the Veteran has been precluded from securing and following gainful employment due to his service-connected disabilities, and TDIU is warranted from June 25, 2007, the date he met the schedular criteria for TDIU. Entitlement to TDIU for the period prior to June 2007 is addressed in the remand. REASONS FOR REMAND Entitlement to service connection for erectile dysfunction, to include as secondary to a service-connected disability is remanded. The claim must be remanded again because the June 2021 VA opinion obtained on remand is inadequate; it is internally inconsistent. The examiner noted that the Veteran's erectile dysfunction was diagnosed in 2011, during the period on appeal, and that the Veteran reported that his conditioned at worsened during the period on appeal. However, the Veteran provided a negative opinion regarding secondary service connection based upon no records indicating an increase in complaints or aggravation of his erectile dysfunction. Additionally, the examiner used the wrong standard for aggravation; the examiner addressed beyond natural progression, rather than the correct "any increase" in disability. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439 (1995). Accordingly, a new opinion is necessary. Entitlement to a TDIU is remanded. The Veteran does not meet the schedular criteria for the award of a TDIU for the period prior to June 2007. However, the evidence indicates that the Veteran may be unemployable due to his service-connected disabilities prior to June 2007. VA policy is to grant a TDIU in all cases where service-connected disabilities preclude gainful employment, regardless of the percentage evaluations. 38 C.F.R. § 4.16 (b). The Board is prohibited from assigning a TDIU based on 38 C.F.R. § 4.16 (b) in the first instance without ensuring that the claim is referred to VA's Director of Compensation Service for consideration of an extraschedular rating. Bowling v. Principi, 15 Vet. App. 1 (2001). Remand is warranted for referral to the Director of Compensation Service for a determination as to the Veteran's entitlement to an extraschedular TDIU for the period prior to June 2007. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the VA examiner who provided June 2021 VA opinion, (or another appropriate provider if June 2021 examiner is unavailable) to determine the nature and likely etiology the Veteran's erectile dysfunction. Copies of all pertinent records must be made available to the examiner for review. The examiner must answer the following: Is it at least as likely as not that the Veteran's erectile dysfunction is (i) caused or (ii) aggravated by (defined as any increase in disability) a service-connected disability? Why or why not? His service-connected disabilities are: residuals of injury to right leg (thigh) with arthritis of the right knee; mood disorder; bilateral hearing loss; tinnitus; hemorrhoids; back disability; and lumbar radiculopathy. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 2. Confirm that the VA medical opinion provided comports with this remand, specifically that the standard for the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. 3. Refer the claim of entitlement to TDIU for the period prior to June 25, 2007, to the Director of Compensation Service for extraschedular consideration pursuant to 38 C.F.R. § 4.16 (b). After the above development, and any additionally indicated development, has been completed, readjudicate the TDIU claim for the entire appeal period (from May 2006). M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Eric Struening 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.