Citation Nr: 21065242 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 16-03 662 DATE: October 25, 2021 ORDER Service connection for bilateral deafness is denied. Service connection for a bilateral hip disorder is denied. Service connection for a neck disorder, characterized as degenerative disc disease of the cervical spine, is denied. Service connection for a bilateral shoulder disorder is denied. Service connection for a back disorder, characterized as degenerative disc disease of the lumbar spine, is denied. Service connection for a bilateral knee disorder is denied. Service connection for a bilateral ankle disorder is denied. Service connection for a bilateral arm disorder is denied. Service connection for carpal tunnel syndrome of the bilateral hands is denied. Service connection for an acquired psychiatric disorder, to include posttraumatic-stress disorder (PTSD) and generalized anxiety disorder, is denied. Service connection for hypertensive cardiovascular disease is denied. Service connection for peripheral neuropathy of the bilateral lower extremities is denied. Service connection for peripheral neuropathy of the bilateral upper extremities is denied. Service connection for a bilateral elbow disorder is denied. Service connection for a bilateral foot disorder is denied. A total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The Veteran's bilateral hip disorder, neck disorder, bilateral shoulder disorder, back disorder, bilateral knee disorder, bilateral ankle disorder, bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, acquired psychiatric disorder, bilateral deafness, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, bilateral elbow disorder, and bilateral foot disorder were not caused by or related to his active duty service. 2. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of PTSD for VA disability compensation purposes. 3. The evidence does not indicate that the Veteran has been unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral deafness have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385. 2. The criteria for service connection for a bilateral hip disorder have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 3. The criteria for service connection for a neck disorder, characterized as degenerative disc disease of the cervical spine, have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 4. The criteria for service connection for a bilateral shoulder disorder have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 5. The criteria for service connection for a back disorder, characterized as degenerative disc disease of the lumbar spine, have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 6. The criteria for service connection for a bilateral knee disorder have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 7. The criteria for service connection for a bilateral ankle disorder have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 8. The criteria for service connection for a bilateral arm disorder have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 9. The criteria for service connection for carpal tunnel syndrome of the bilateral hands have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 10. The criteria for service connection for an acquired psychiatric disorder, to include PTSD and generalized anxiety disorder, have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304. 11. The criteria for service connection for hypertensive cardiovascular disease have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 12. The criteria for service connection for peripheral neuropathy of the bilateral lower extremities have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 13. The criteria for service connection for peripheral neuropathy of the bilateral upper extremities have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 14. The criteria for service connection for a bilateral elbow disorder have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 15. The criteria for service connection for a bilateral foot disorder have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 16. The criteria for TDIU have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1955 to September 1957. The Board also observes that in correspondence, including December 2014 and August 2015 letters, the Veteran was informed that his service treatment records were destroyed in a fire at the National Archives and Records Administration. The Board acknowledges that all of the Veteran's service treatment records were destroyed in the fire or remain missing. In cases where records are presumed to have been or were destroyed when they were in the possession of the government, there is a heightened obligation to assist the Veteran in the development of the case, to explain findings and conclusions, and to carefully consider the benefit of the doubt rule. See Washington v. Nicholson, 19 Vet. App. 362, 369- 70 (2005); see also Cromer v. Nicholson, 19 Vet. App. 215, 217 (2005) (citing O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991)). Notwithstanding this heightened obligation, the legal standard for proving a claim seeking service connection is not lowered. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131. Generally, the evidence must show: (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, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases may be presumed to have been incurred during service if they become manifested to a compensable degree within one year from separation from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). This presumption is rebuttable by affirmative evidence to the contrary. Id. Moreover, evidence of continuous symptoms since active duty is a factor for consideration as to whether a causal relationship exists between an in-service injury or incident and the current disorder as is contemplated under 38 C.F.R. § 3.303(a). 1. Entitlement to service connection for bilateral deafness 2. Entitlement to service connection for a bilateral hip disorder 3. Entitlement to service connection for a neck disorder, characterized as degenerative disc disease of the cervical spine 4. Entitlement to service connection for a bilateral shoulder disorder 5. Entitlement to service connection for a back disorder, characterized as degenerative disc disease of the lumbar spine 6. Entitlement to service connection for a bilateral knee disorder 7. Entitlement to service connection for a bilateral ankle disorder 8. Entitlement to service connection for a bilateral arm disorder 9. Entitlement to service connection for carpal tunnel syndrome of the bilateral hands 10. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and generalized anxiety disorder 11. Entitlement to service connection for hypertensive cardiovascular disease 12. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities 13. Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities 14. Entitlement to service connection for a bilateral elbow disorder 15. Entitlement to service connection for a bilateral foot disorder The Veteran contends that service connection is warranted for bilateral deafness, a bilateral hip disorder, a neck disorder, a bilateral shoulder disorder, a back disorder, a bilateral knee disorder, a bilateral ankle disorder, a bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, an acquired psychiatric disorder, including PTSD and an anxiety disorder, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, a bilateral elbow disorder, and a bilateral foot disorder. PTSD The Veteran contends that service connection for PTSD is warranted because it began during his military service in France. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), a link established by medical evidence between current symptoms and an in-service stressor, and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. §§ 3.304(f). Pursuant to 38 C.F.R. § 4.125(a), a diagnosis of PTSD must conform to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Based upon the evidence of record, the Board determines that service connection for PTSD is not warranted because the Veteran does not have a diagnosis of PTSD for VA compensation purposes. Specifically, no treatment records reflect that he has been diagnosed with PTSD under the DSM-5. The Board acknowledges that a June 2014 treatment record from his private physician (Dr. Mora Quesada), indicates that the Veteran was diagnosed with PTSD by his private physician. Nevertheless, the Board concludes that this PTSD diagnosis does not constitute a PTSD diagnosis for VA compensation purposes because the private physician did not consider the DSM-5 criteria, and therefore the diagnosis did not conform with the DSM-5. Thus, although the record reflects the presence of some psychiatric symptoms, these symptoms alone without an underlying PTSD diagnosis are insufficient to establish service connection for PTSD. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). Disorders other than PTSD The Veteran contends that his current bilateral deafness, bilateral hip disorder, neck disorder, bilateral shoulder disorder, back disorder, bilateral knee disorder, bilateral ankle disorder, bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, acquired psychiatric disorder, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, bilateral elbow disorder, and bilateral foot disorder began during or were caused by the duties that he performed during his active duty service, including lifting and marching. With respect to his back disorder, he asserts that it is related to an in-service incident where he hurt his back when attempting to pick up a wheelbarrow filled with cement and fell on his back. Based upon the evidence of record, the Board determines that service connection is not warranted for the Veteran's bilateral deafness, bilateral hip disorder, neck disorder, bilateral shoulder disorder, back disorder, bilateral knee disorder, bilateral ankle disorder, bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, acquired psychiatric disorder, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, bilateral elbow disorder, and bilateral foot disorder because the preponderance of the evidence weighs against finding that they began during service or are otherwise etiologically related to service. 38 U.S.C. §§ 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303(a), (d), 3.304, 3.307, 3.309, 3.310. In this case, the post-service evidence fails to show that the Veteran has experienced continuous symptoms related to a bilateral deafness, bilateral hip disorder, a neck disorder, a bilateral shoulder disorder, a back disorder, a bilateral knee disorder, a bilateral ankle disorder, a bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, bilateral deafness, an acquired psychiatric disorder other than PTSD, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, a bilateral elbow disorder, and a bilateral foot disorder such that service connection would be warranted by such continuous symptoms. In this case, the clinical evidence of record shows significant gaps between the Veteran's separation from service and when he first sought treatment for these disorders after his separation from service in September 1957: With respect to bilateral deafness, the objective medical evidence does not show a diagnosis of, any symptoms of, or any treatment for symptoms that could be related to bilateral deafness until April 2009, more than 51 years after his separation from service. With respect to a neck disorder, the objective medical evidence does not show a diagnosis of, any symptoms of, or any treatment for symptoms that could be attributed to a neck disorder until March 1988, more than 30 years after his separation from service. With respect to a back disorder, the objective medical evidence does not show a diagnosis of, any symptoms of, or any treatment for symptoms that could be attributed to a back disorder until March 1988, more than 30 years after his separation from service. With respect to a bilateral hip disorder, a bilateral shoulder disorder, a bilateral knee disorder, a bilateral ankle disorder, a bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, a bilateral elbow disorder, and a bilateral foot disorder, the objective medical evidence does not show a diagnosis of, any symptoms of, or treatment for symptoms that could be attributed to a bilateral hip disorder, a bilateral shoulder disorder, a bilateral knee disorder, a bilateral ankle disorder, a bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, a bilateral elbow disorder, and a bilateral foot disorder until June 2014, more than 56 years after his separation from service. With respect to an acquired psychiatric disorder other than PTSD, the objective medical evidence does not show a diagnosis of, any symptoms of, or treatment for symptoms that could be attributed to an acquired psychiatric disorder other than PTSD until March 1974, more than 16 years after his separation from service. The date of treatment for symptoms that could be attributed to an acquired psychiatric disorder is based upon a certification from a medical center, which indicates that was a patient of the medical center from March 1974 to October 1997, and that the center provided mental health services. With respect to hypertensive cardiovascular disease, the objective medical evidence does not show a diagnosis of, any symptoms of, or treatment for symptoms that could be attributed to hypertensive cardiovascular disease until October 2008, more than 51 years after his separation from service. With respect to peripheral neuropathy of the bilateral lower extremities, the objective medical evidence does not show a diagnosis of, any symptoms of, or any treatment for symptoms that could be attributed to peripheral neuropathy of the bilateral lower extremities until May 2009, more than 51 years after his separation from service. With respect to peripheral neuropathy of the bilateral upper extremities, the objective medical evidence does not show a diagnosis of, any symptoms of, or any treatment for symptoms that could be attributed to peripheral neuropathy of the bilateral upper extremities until May 2009, more than 51 years after his separation from service. Given the significant gaps between his separation from service in November 1968 and when he first sought treatment for these disorders, a continuity of symptoms based upon the clinical evidence is not sufficient to support a direct nexus. The Board acknowledges the Veteran's statements regarding the history of his symptoms of bilateral deafness, a bilateral hip disorder, a neck disorder, a bilateral shoulder disorder, a back disorder, a bilateral knee disorder, a bilateral ankle disorder, a bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, an acquired psychiatric disorder other than PTSD, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, a bilateral elbow disorder, and a bilateral foot disorder. Although he is competent to report that he experienced the symptoms of these disorders, he is not competent to determine that these symptoms were manifestations of a particular disorder. See Jandreau, 492 F.3d at 1377, 1377 n.4. Nevertheless, to the extent that the Veteran contends that his bilateral deafness, bilateral hip disorder, neck disorder, bilateral shoulder disorder, back disorder, bilateral knee disorder, bilateral ankle disorder, bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, acquired psychiatric disorder other than PTSD, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, bilateral elbow disorder, and bilateral foot disorder have persisted since his active duty service, the Board determines that the reported history of continued symptoms is not credible and does not establish the nexus element because, as discussed above, the evidence shows that he did not seek treatment for these disorders for significant durations after separation from service. The fact that he did not seek treatment for these significant durations after his service weighs against his credibility to the extent that he asserts continuous symptoms of these disorders. See Kahana v. Shinseki, 24 Vet. App. 428, 439-40 (2011). Moreover, the Veteran's contention that he has experienced continuous symptoms of a bilateral hip disorder, a neck disorder, a bilateral shoulder disorder, a back disorder, a bilateral knee disorder, a bilateral ankle disorder, a bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, an acquired psychiatric disorder other than PTSD, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, a bilateral elbow disorder, and a bilateral foot disorder since service is not credible because it is belied by the clinical evidence. With respect to a bilateral hip disorder, a bilateral knee disorder, a bilateral ankle disorder, a bilateral shoulder disorder, a bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, a bilateral elbow disorder, and a bilateral foot disorder, his claim of continuous symptoms is not credible and belied by the clinical evidence. The only diagnosis of such disorder is set forth in the June 2014 treatment record of his private physician. Numerous other treatment records, including October 2008, June 2010, March 2015, September 2016, and January 2017 treatment records, reflect that the range of motion of his musculoskeletal system was intact, his muscle tone was adequate, and that there were no deformities. With respect to peripheral neuropathy of the bilateral upper and lower extremities, the Veteran's claim of continuous symptoms is similarly not credible and belied by the clinical evidence. Indeed, numerous treatment records, including October 2008, June 2010, July 2015, and May 2017 treatment records, reflect that he had no gross motor and sensory deficit. With respect to a neck disorder, the Veteran's claim of continuous symptoms again is not credible and belied by the clinical evidence. Although some treatment records do reflect neck pain and osteoarthritis, other treatment records, including August 2018 and October 2019, reflect normal neck examinations. With respect to a back disorder, the Veteran's claim of continuous symptoms of his current back disorder is also not credible and belied by the clinical evidence. In this case, a July 2019 treatment record reflects that he reported back pain due to a back injury that he sustained when he slipped on the sidewalk. Moreover, various treatment records, including the October 2008, June 2010, March 2015, September 2016, and January 2017 treatment records, reflect that the range of motion of his musculoskeletal system was adequate and did not indicate that he experienced any issues related to his back. With respect to an acquired psychiatric disorder, the Veteran's claim is similarly not credible and belied by the clinical evidence. Although some treatment records do reflect that he reported psychiatric symptoms, numerous treatment records, including October 2008, May 2016, and September 2018 treatment records, reflect that he had negative depression screenings, reported that he was not feeling down or depressed, and do not reflect that he experienced anxiety. Additionally, other treatment records, including a June 2015 treatment record, reflect that he began experiencing depression after his wife "abandoned" him in 1972, and that he attributed that depression to his wife abandoning him and not his military service. Given that the clinical evidence contradicts his claims of continuous symptoms, his claims of continuous symptoms are not credible and a continuity of symptoms of bilateral deafness, a bilateral hip disorder, a neck disorder, a bilateral shoulder disorder, a back disorder, a bilateral knee disorder, a bilateral ankle disorder, a bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, an acquired psychiatric disorder other than PTSD, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, a bilateral elbow disorder, and a bilateral foot disorder cannot be established based upon the Veteran's assertions. Finally, service connection may be granted when the evidence establishes a medical nexus between active duty service and the current diagnosis. However, there is not sufficient evidence in the medical records to demonstrate a nexus between the Veteran's active duty service and bilateral deafness, a bilateral hip disorder, a neck disorder, a bilateral shoulder disorder, a back disorder, a bilateral knee disorder, a bilateral ankle disorder, a bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, an acquired psychiatric disorder other than PTSD, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, a bilateral elbow disorder, and a bilateral foot disorder. The Board initially notes that there is no objective evidence linking the Veteran's bilateral deafness, bilateral hip disorder, neck disorder, bilateral shoulder disorder, back disorder, bilateral knee disorder, bilateral ankle disorder, bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, acquired psychiatric disorder other than PTSD, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, bilateral elbow disorder, and bilateral foot disorder to an event during his active duty service. Next, with respect to a back disorder, the Board places significant probative weight on the report from the April 2021 VA examination. The examination report reflects that the examiner opined that the Veteran's back disorder was less likely than not incurred in or caused by his active duty service. In support of that opinion, the examiner explained that the Veteran's back disorder was not etiologically related to his active duty service because the medical evidence did not establish a chronicity of care, the medical evidence did not show complaints related to or treatment for a back disorder during his active duty service, the Veteran's lay statement that he injured his lower back during active duty service did not support an etiological relationship between his active duty service and his back disorder because of the lack of chronicity of care or treatment in proximity to his discharge, and the June 2014 opinion by his private physician (Dr. More Quesada) was not sufficient to establish an etiological relationship between his back disorder and his active duty service because it lacked a physical examination and was based solely on the Veteran's statements without a review of his military records or other available records. Given the April 20201 VA examiner's expertise, review of the claims file, well-supported rationale, and in-person examination, the Board finds that the examiner's opinion is entitled to substantial probative weight. In contrast, the June 2014 opinion of the Veteran's private physician (Dr. More Quesada), opining that the Veteran's bilateral deafness, hypertensive cardiovascular disease, neck disorder, bilateral shoulder disorder, carpal tunnel syndrome of the bilateral hands, back disorder, bilateral hip disorder, bilateral knee disorder, bilateral ankle disorder, bilateral foot disorder, peripheral neuropathy of the upper and lower extremities, PTSD, and anxiety disorder are etiologically related to his active duty service, is not entitled to probative weight. As explained by the April 2021 VA examiner, the opinion is not probative because the physician did not review the claims file or perform a physical examination. Additionally, the physician did not provide a rationale for the opinion rendered, and simply indicated that service connection was warranted for the foregoing conditions based upon the Veteran's lay statements without considering whether those statements were supported by the medical evidence. Accordingly, the Board concludes that the physician's opinion is not probative and does not establish an etiological relationship between these disorders and the Veteran's active duty service. In arriving at its conclusion, the Board has also considered the Veteran's statements relating his bilateral deafness, bilateral hip disorder, neck disorder, bilateral shoulder disorder, back disorder, bilateral knee disorder, bilateral ankle disorder, bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, acquired psychiatric disorder other than PTSD, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, bilateral elbow disorder, and bilateral foot disorder to his active duty service. The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau, 492 F.3d at 1377). In this case, however, the Veteran is not competent to provide testimony regarding the etiology of his bilateral deafness, bilateral hip disorder, neck disorder, bilateral shoulder disorder, back disorder, bilateral knee disorder, bilateral ankle disorder, bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, acquired psychiatric disorder other than PTSD, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, bilateral elbow disorder, and bilateral foot disorder. See Jandreau, 492 F.3d at 1377, n.4. Although he can provide competent testimony regarding symptoms, these disorders are not disorders that can be diagnosed by their unique and identifiable features as they do not involve a simple identification that a layperson is competent to make. In any event, the diagnoses of dysfunctions and disorders, and their respective etiologies, are medical determinations and generally must be established by medical findings and opinion. See id. at 1376-77. Thus, to the extent that the Veteran believes that the claimed disorders were the result of his active duty service, he is a lay person without appropriate medical training and expertise to provide a medical diagnosis and etiological opinion. By virtue of the foregoing, the Board concludes that the preponderance of the evidence is against the claims seeking service connection for bilateral deafness, a bilateral hip disorder, a neck disorder, a bilateral shoulder disorder, a back disorder, a bilateral knee disorder, a bilateral ankle disorder, a bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, an acquired psychiatric disorder, to include PTSD and an anxiety disorder, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, a bilateral elbow disorder, and a bilateral foot disorder, and there is no doubt to be otherwise resolved. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU 16. Entitlement to TDIU The Veteran contends that he has been unable to due to the disorders for which he sought service connection and his service-connected tinnitus. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). The Board must consider if the Veteran can obtain employment more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce to be the poverty threshold for one person. See Ray v. Wilkie, 2019 U.S. App. Vet. Claims LEXIS 386 (Mar. 14, 2019). Further, the Board should also consider whether given the Veteran's history, education, skill, and training, in conjunction with the Veteran's physical ability and mental ability, can perform the type of activities required by the occupation at issue. See Id. Moreover, the Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected conditions and advancing age, which would justify TDIU. 38 C.F.R. §§ 3.341(a), 4.19; See Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). A total disability rating for compensation purposes may be assigned on the basis of "individual unemployability," or when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. In such an instance, if there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). If a veteran fails to meet the threshold minimum percentage standards enunciated in 38 C.F.R. § 4.16(a), rating boards should refer to the Director of Compensation and Pension Service for extra-schedular consideration all cases where the veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). Thus, the Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected conditions and advancing age, which would justify TDIU. 38 C.F.R. §§ 3.341(a), 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The veteran's service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). After a review of the evidence of record, the Board determines that TDIU is not warranted because the Veteran's service-connected tinnitus does not prevent him from securing or following a substantially gainful occupation. As a threshold matter, the Veteran does not meet the schedular criteria for TDIU for any portion of the period on appeal. Specifically, the Veteran has only been granted service connection for tinnitus, which is rated as 10 percent disabling (effective June 24, 2014). Thus, he has a total combined rating of 10 percent, and does not meet the schedular criteria for TDIU because he does not have a combined rating of 70 percent or a single disability rated as 40 percent disabling. Next, the Board finds that referral for extraschedular consideration is not warranted because the Veteran's service-connected tinnitus does not prevent him from securing or following a substantially gainful occupation. See 38 C.F.R. § 4.16(b). In this case, the Veteran has only been granted service connection for tinnitus. The medical evidence does not indicate that his service-connected tinnitus has prevented him from securing or following a substantially gainful occupation. Specifically, the report from the March 2020 VA examination reflects that his tinnitus makes his internal ear sound more noticeable in a quiet environment. The examination does not reflect that the examiner determined or opined that his tinnitus had any impact on his ability to work or prevented him from securing or following a substantially gainful occupation. Similarly, his treatment records do not reflect that his tinnitus has prevented him from securing or following a substantially gainful occupation. The Board acknowledges that the June 2014 opinion by the Veteran's private physician reflects that his private physician opined that the Veteran was 100 percent disabled and that his service-connected disability significantly impacted his ability to perform work in a competitive work environment. The Board finds that this opinion does not show that the Veteran's service-connected tinnitus prevents him from securing or following a gainful occupation and is not probative. Initially, the opinion is based upon numerous disorders for which the Veteran has been denied service connection herein. Moreover, the private physician provides no rationale and does not expressly address how the Veteran's tinnitus impacts his ability to work. Accordingly, the Board concludes that this opinion does not establish that the Veteran's service-connected tinnitus prevents him from securing or following a substantially gainful occupation. The Board also notes that the evidence of record shows that the Veteran completed two years of high school, last worked in 1974 for an automobile company, and was a carpenter during his active duty service. Although the Veteran's educational background supports his application for TDIU, the evidence does not show that his service-connected tinnitus has prevented him from performing the duties that he performed while working at the automobile company or the duties of a carpenter. Such experience could be utilized to obtain employment. Instead, the Veteran's application for TDIU relies principally on his nonservice-connected disorders, and the contention that those disorder caused him to be unable to perform his duties at the automobile company and the duties of a carpenter. Thus, the Board finds that his service-connected tinnitus does not prevent him from securing or following a substantially gainful occupation. Moreover, the Board finds that the clinical evidence is sufficient for the Board to make its own conclusions. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner). In this regard, the Board also notes the most probative evidence, including the reports from the March 2020 VA examination and the clinical evidence, does not support a finding that referral for extraschedular TDIU consideration is warranted based upon his service-connected tinnitus. By virtue of the foregoing, the Board concludes that service connection for a bilateral hip disorder, a neck disorder, a bilateral shoulder disorder, a back disorder, a bilateral knee disorder, a bilateral ankle disorder, a bilateral arm disorder, carpal tunnel syndrome of the bilateral hands, bilateral deafness, an acquired psychiatric disorder, to include PTSD and generalized anxiety disorder, hypertensive cardiovascular disease, peripheral neuropathy of the bilateral lower extremities, peripheral neuropathy of the bilateral upper extremities, a bilateral elbow disorder, and a bilateral foot disorder is not warranted, and that TDIU is not warranted. 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. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Crosnicker, Associate Counsel