Citation Nr: 21065941 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 09-17 185 DATE: October 28, 2021 ORDER Entitlement to separate compensation for neurologic abnormalities, to include bowel or bladder impairment, secondary to service-connected lumbar spine disability is denied. Entitlement to service connection for a disability manifested by tremors, to include as secondary to service-connected disabilities is denied. Entitlement to service connection for a bilateral arm disability, to include bursitis, and other than cervical radiculopathy of the upper extremities and tremors, to include as secondary to service-connected disabilities is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) from May 4, 2011 is dismissed as moot. Entitlement to TDIU prior to May 4, 2011 is denied. FINDINGS OF FACT 1. The preponderance of the evidence shows the Veteran's bladder and/or bowel impairment was not caused or aggravated by a service-connected lumbar spine disability. 2. Tremors were not shown in service or within a year of discharge; and, the preponderance of the evidence shows the Veteran's tremors are not caused or aggravated by active service or any service-connected disability. 3. A bilateral arm disability, including bursitis, and other than cervical radiculopathy and tremors, was not shown in service or within a year of discharge; and, the preponderance of the evidence shows the Veteran's bursitis is not caused or aggravated by active service or any service-connected disability. 4. As a total (100 percent) rating and special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114 (s) has been awarded for the entire period from May 4, 2011, the issue of entitlement to a TDIU during this period is rendered moot. 5. The preponderance of the evidence shows the Veteran is not preclude from securing and following substantially gainful employment solely due to service-connected disabilities prior to May 4, 2011. CONCLUSIONS OF LAW 1. The criteria for a separate compensation for neurologic abnormalities, to include bowel or bladder impairment, secondary to service-connected lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for a disability manifested by tremors, to include as secondary to service-connected disabilities have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for a bilateral arm disability, to include bursitis, and other than cervical radiculopathy of the upper extremities and tremors, to include as secondary to service-connected disabilities have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 4. The question of whether the Veteran is entitled to a TDIU, from May 4, 2011, is rendered moot by his receipt of a total (100 percent) rating and the award of SMC pursuant to 38 U.S.C. § 1114 (s) during this period, leaving no question of law or fact to decide regarding the TDIU issue during this period. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.340, 3.341, 4.14, 4.16. 5. The criteria to a TDIU prior to May 4, 2011 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.341, 4.1, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1977 to January 1980 and from October 1982 to October 1984. He had additional service with the Army National Guard from November 1986 to March 1995, which included a period of inactive duty for training (INACDUTRA) in June 1992. These matters come before the Board of Veterans' Appeals (Board) from July 2007 and June 2013 rating decisions. The Board remanded these issues in June 2017 and February 2021 for further development. There has been substantial compliance with the February 2021 remand directives and these matters are properly before the Board for adjudication. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Preliminary Considerations As a preliminary matter, the Veteran, through his former counsel, broadly challenged the adequacy of every VA examination in an October 2014 letter. The Board points out most of the arguments submitted are sweeping, general, overbroad, and duplicative statements of law. In this case the Veteran's attorney stated that VA did not provide the Veteran the benefit of the doubt, discounted favorable evidence, refused to provide a new examination, put forth inadequate reasons and bases for denial of the Veteran's claims, failed to obtain all medical records, mischaracterized evidence, refused due process, and failed to address medical treatises. The arguments put forth by Veteran's former counsel fail to point to any specific error. The Board has reviewed these arguments and finds they have no basis. The Veteran was provided with multiple VA examinations during the period on appeal and the examination reports set forth detailed findings in a manner which allows for informed appellate review under applicable VA laws and regulations and the Board finds the examinations to be sufficient for appellate review and of high probative value. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). As for the Veteran's argument that VA ignored favorable evidence, the Board finds no such evidence nor does the Veteran identify favorable evidence overlooked by VA. Hence, the Board finds the VA examination reports during the relevant period are adequate, and that these reports, along with the other evidence of record, provide sufficient information for resolutions of these claims. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). 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). Service connection for a disability requires evidence of: (1) a current disability; (2) a disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability that is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may be established for a disorder that is caused or aggravated by a service-connected disability. Id. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 44748 (1995). To establish secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 511 (1998). Certain chronic diseases may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C. § 101(21), (24); 38 C.F.R. § 3.6(a), (d); Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Generally, when a claim for service connection is based upon an injury that occurred during a period of ACDUTRA or INACDUTRA, presumptive periods and the presumption of sound of condition do not apply, regardless of whether the individual had a prior period of active service. Smith v. Shinseki, 24 Vet. App. 40, 44-46 (2010); Biggins, 1 Vet. App. at 477-78. Even though a disease is not included on the list of presumptive diseases, a nexus between the disease and service may nevertheless be established on the basis of direct service connection. Stefl v. Nicholson, 21 Vet. App. 120 (2007). When a claimed disability is not included as a presumptive disability, direct service connection may nevertheless be established by evidence demonstrating that the disability was in fact incurred during service. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). 2. Entitlement to separate compensation for neurologic abnormalities, to include bowel or bladder impairment, secondary to service-connected lumbar spine disability is denied. The Veteran contends compensation is warranted for current neurologic abnormalities, including bowel and/or bladder impairment. The Board will address secondary service connection first. Medical treatment records show the Veteran complained of bladder control and incontinence in September 2017 and January 2018. The Veteran's lumbar spine disability is service-connected, effective October 30, 2006. Wallin elements (1) and (2) are met. Turning to element (3), a nexus, the Veteran underwent a VA examination in February 2015. The examiner opined that urinary and fecal incontinence may be caused by the service-connected lumbar condition. A January 2016 VA examiner reviewed the Veteran's claims file, medical records, examination reports, and conducted an in-person examination. The 2016 examination report indicates the Veteran has daily urinary incontinence which does not require the use of a pad, and experiences diarrhea or fecal incontinence if he over-indulges in fatty food. In June 2021, the Veteran underwent a VA examination and the examiner diagnosed neurogenic bladder disorder. After reviewing the Veteran's medical records, lay statements, claims file, and conducting an in-person examination, the examiner opined that the claimed bowel and bladder neurological abnormalities were less likely caused by or aggravated the service-connected low back injury. He explained that the neurogenic bladder was likely related to his non-service-connected tremor, Parkinson's disease, and Carbidopa-levodopa (medication used to treat tremors and/or Parkinson's). The Board finds the June 2021 VA examination report to be highly probative, sufficiently rationalized, and is based on thorough review of the record. There are no competent medical opinions to the contrary. Moreover, VA treatment records support the June 2021 examiner's findings. Specifically, the Veteran reported he needed additional pads because of urinary incontinence in February 2017. March 2017 and June 2017 treatment notes show the Veteran was voiding every two hours with extreme urgency and occasional incontinence. The physician contributed this to Parkinson's Disease. The March 2017 physician also explained that the symptoms of overactive bladder and urinary retention occur due to bradykinesia, a cardinal manifestation of Parkinson's disease, and treating Parkinson's may also reduce bladder overactivity and lead to better voiding function. However, the Veteran was informed that aggressively treating the bladder complaints may interfere with the management of Parkinson's disease. A September 2017 Cervical Spine examination report shows the Veteran stated he experienced occasional urinary incontinence because he is unable to reach the bathroom in time. A January 2018 neurosurgery report again indicated that the Veteran's bladder control is associated with Parkinson's disease and he denied fecal incontinence and saddle anesthesia. As such, the preponderance of the evidence is against a finding that the Veteran's current neurologic abnormalities, including bowel and/or bladder impairment is related to his service-connected lumbar spine disability under a secondary service connection theory. Turning to direct service connection, the evidence does not show, nor has the Veteran alleged that his current neurologic abnormalities, including bowel and/or bladder impairment were caused by or aggravated by periods of active service or an injury during INACDUTRA. Moreover, the competent evidence of record shows that the Veteran denied urinary or fecal incontinence in March 2011, May 2011, June 2012, August 2012, and May 2014. The first indication the Veteran experienced urinary or fecal incontinence was in February 2015, approximately 31 years after active service and 23 years after INACDUTRA. The record shows he reported trouble urinating as a result of tremors; however, this statement fails to show incontinence. Additionally, as noted above, the presumptions of soundness and in-service incurrence for certain chronic disability do not generally apply to ACDUTRA or INACDUTRA. Therefore, the Board finds that the preponderance of the evidence is against a finding that the Veteran has neurologic abnormalities, including bowel and/or bladder impairment as a result of service, manifested to a compensable degree within one year of discharge from service, or continuity of symptomatology after service. For the foregoing reasons, the Veteran's claim for service connection for neurologic abnormalities, including bowel and/or bladder impairment must be denied under all theories of service connection. 3. Entitlement to service connection for a disability manifested by tremors, to include as secondary to service-connected disabilities is denied. The Veteran contends his tremor disability was caused or aggravated by active service, including periods of INACDUTRA from 1992 to 1995 and/or all his service-connected disabilities. 1979 and 1984 separation examination reports indicate the Veteran's neurologic and upper extremities were normal. He denied lameness, neuritis, paralysis, epilepsy or fits. Service treatment records show the Veteran fell while on duty in June 1992. The Veteran complained of bilateral upper extremity pain in July 1993. His treating physician ordered an EMG which came out negative and no muscle atrophy was noted in the upper extremities. On September 20, 1993, the Veteran reported aching pain in his arms, left side pain was notably greater than the right side. A May 1994 Medical Evaluation Board report found the in-service injury resulted in lower thoracic pain with radiation up and down his, and occasionally down the left leg. The Veteran's physical examination was within normal limits except for limitations related to the back injury. The report noted that the Veteran was unable to sit or stand greater than 15 minutes, lift anything greater than 10 pounds, or run. The Veteran declined an opportunity to rebut the Medical Board's findings, contents, opinions, or recommendations in June 1994. The Veteran has a strong family history of Parkinson's disease, which includes his mother, maternal grandmother, and maternal aunt. After leaving service, the Veteran consulted Dr. G.D., M.D. in August 2000 and March 2002. Dr. G.D.'s neurology report shows the Veteran's hand tremors began in 1997. They typically appear writing or typing and do not occur while his hands are at rest. Dr. G.D. believed the tremor was familial because the Veteran's mother and grandmother had similar tremors. Private medical records dated July 22, 2004 indicate the Veteran reported suffered a stroke in 1995 or 2000 which resulted in numbness on one side and CT brain scans were unremarkable. The Veteran stated that his mother experienced similar tremors, and his grandmother and her two sisters had tremors or Parkinson's disease. The physician indicated that the Veteran had essential tremor or familial tremor; however, there was no evidence Parkinson's disease, yet. Social Security Administration (SSA) records reflect the Veteran requested medical leave in May 2006 due to tremors and other medical issues. The Veteran indicated tremors impact both hands and fingers, and manifest as daily shaking, burning, and tingling. He cut himself shaving and drops food while eating. An August 17, 2006 neurological note revealed the Veteran's mild essential tremor did not improve with Inderal and he discontinued Topamax because the side-effects were intolerable. VA treatment records dated August 9, 2009 reflect the Veteran visited several doctors for treatment of his tremors and was given several conflicting diagnoses. The Veteran was unsure of his diagnosis, frustrated, fell regularly, and was hospitalized. The Veteran was diagnosed with Parkinson's disease in 2010. A March 2011 neurology clinic note indicated that the Veteran was initially felt to have essential tremor. The tremor progressed to higher intensity and the lower extremities were affected. The Veteran's tremor was present at rest and posture, and limited his ability to do many things, including buttoning clothes, tying shoelaces, shaving, eating, writing, and brushing his teeth. He also noted full body stiffness and slowness of movement. The Veteran was evaluated at the Parkinson's institute. The physicians there felt that his symptoms were secondary to idiopathic Parkinson's disease but that there may also be a large component of functional overlay. An August 2011 neurologist evaluated the Veteran and stated that the tremor was most likely not Parkinson's disease and has a somatoform component along with depression and alcohol abuse. Dr. P.H., M.D., indicated treatment would be difficult if the Veteran did not accept the psychological component to his tremor and that he has an alcohol problem. The treating physician encouraged the Veteran to stop drinking and follow-up with mental health counseling. The Veteran was seen by Dr. S.S. in December 2011 for worsening tremors. Dr. S.S. indicated the tremors were atypical for Parkinson's disease and that there may be underlying essential tremors with additional somatoform components. Dr. S.S. explained that even remote psychological issues such as depression, frustration due to back pain, anxiety, etc., can worsen or enhance tremors. A May 2013 neurologist note indicated the Veteran's tremor is atypical for a classic essential tremor, and felt it was more consistent with psychogenic movement disorder, with some underlying tremor in addition. The Veteran was debilitated by his condition, and a combination of behavioral and pharmacological treatment was recommended. The staff neurologist at VA gently told him that his tremor is predominantly psychogenic and both factors need treatment. In July 2015, a VA neurologist noted that the Veteran's tremors are less likely psychogenic given they are present during distraction. She explained that they may represent a complex picture including elements of atypical Parkinson's disease and essential tremor. The Veteran's UPDRS score was high, he has a strong family history of Parkinson's disease, and his symptoms display asymmetry consistent with Parkinson's. Moreover, the tremors are partially suppressible. A January 2017 treatment note stated the Veteran present with decreased blink rate, very mild rigidity, incoordinated fast movements, and near constant at rest and action tremors. The physician believed these symptoms suggest Parkinson's disease and some degree of functional overlay. The Veteran underwent multiple VA examinations in order to obtain an adequate medical opinion regarding the etiology of his tremors. An April 2007 VA examiner noted occasional tremors of the right upper extremity were thought to be related to his underlying anxiety and were essential in nature. A September 2017 VA examiner explained there was no medical evidence documenting a cause or diagnosis to account for these tremors nor was there a plausible medical explanation to support that these tremors are caused by or aggravated by service, the in-service back injury on June 5, 1992, degenerative changes to the cervical spine, or the Veteran's depression or treatment for the depression. The examiner also stated the tremors were less likely than not to have manifested within one year immediately following either periods of service. However, the VA examiner conceded that depression could have aggravated tremors because VA treatment providers indicated the Veteran's tremors could be aggravated by a psychiatric disorder such as depression and/or the usage of duloxetine which could cause tremors. A June 2021 VA examiner reviewed the Veteran's records, conducted an in-person examination, and considered his lay statements. The examiner opined the tremors were less likely than not caused by or aggravated by service or a service-connected disability, and the tremors did not manifest within one year of discharge from service or the June 1992 in-service injury. The report indicated that the Veteran's earliest appearance of a nerve condition is in 2006, approximately 22 years after discharge from service and 14 years after his June 1992 injury. The examiner explained he believed the Veteran suffers from Parkinson's disease even though many VA neurologists were unable to agree on whether or not the Veteran has Parkinson's. Additionally, the examiner pointed out that VA neurologists indicated the Veteran's tremors are psychogenic due to conversion disorder and therefore agreed that the claimed disability maybe secondary to conversion disorder. The Board finds the preponderance of the evidence is against awarding service connection for tremors under any theory of entitlement. The Veteran has been diagnosed with essential tremors and service treatment records indicate he suffered a back injury during INACDUTRA. Shedden elements (1) and (2) are met. Turning to element (3), a nexus, the Veteran underwent multiple VA examinations and sought treatment from various neurologists in order to determine the cause of his disability. September 2017 and June 2021 VA examiners determined the tremors were less likely than not caused by or aggravated by service. The 2021 examiner explained the earliest appearance of a nerve condition is in 2006 and VA treatment records indicate the earliest report of tremors was around 1997. The Veteran's service treatment records showed he denied neurologic disabilities, upper extremities disorders, lameness, neuritis, paralysis, epilepsy, or fits. A 1993 EMG no neurologic disability and no muscle atrophy was noted in the upper extremities. Despite reports of aching pain in his arms, a May 1994 Medical Evaluation Board report found the Veteran's physical examination was within normal limits except for limitations related to the back injury. The Board affords the examiner's opinion great weight, as it was based on medical principles and adequate rationale, and the examiner considered the Veteran's lay statements and history of symptom manifestation. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). There are no competent opinions to the contrary. The regulations concerning presumptive service connection, the presumption of soundness, and the presumption of aggravation are inapplicable to claims based upon INACDUTRA service. See Smith v. Shinseki, 24 Vet. App. 40 (2010). However, pursuant to 38 U.S.C. § 101(24)(C) active military service, to which presumptive service connection applies, includes any period of INACDUTRA which an individual is disabled from an injury incurred or aggravated in line of duty. See 38 U.S.C. § 101(24)(C). The preponderance of the evidence is against finding the claimed tremors manifested within one year of active service or the 1992 in-service injury. The Veteran does not contend otherwise. Similarly, the preponderance of the evidence indicates tremors did not manifest in continuity of symptomatology after service. Service treatment records show the Veteran fell while during INACDUTRA in June 1992. Post-service treatment records show the Veteran's reported his hand tremors began in 1997, five years after his in-service injury. The Veteran's treating neurologist submitted reports in August 2000 and March 2002 which reflect the Veteran's hand tremors were familial because the Veteran's mother and grandmother had similar tremors. Moreover, the September 2017 and June 2021 VA examiners determined the tremors did not manifest within one year of active service or the 1992 in-service injury, nor was there evidence of continuity of symptomatology based on a thorough review of the claims file. The preponderance of the evidence indicates shows that the claimed disability manifested greater than one year after service and was not a result of active service. Moreover, VA and private treatment records and VA examination reports do not even remotely suggest his tremors were caused by service, directly or indirectly. Turning to the claim for secondary service connection, the Veteran has several service-connected disabilities and Wallin elements (1) and (2) are met. Wallin element (3) requires a connection between the service-connected disability and the current disability. The preponderance of the evidence is against finding tremors were caused or aggravated by a service-connected disability. Neurologists, psychologists, and VA examiners have been unable to agree upon the cause of the Veteran's tremors. The diagnoses and causes include a familial history of tremors, Parkinson's disease, idiopathic tremors, idiopathic Parkinson's disease, psychogenic causes, alcoholism, somatoform causes, atypical Parkinson's with functional overlay, depression, medication used for depression, anxiety, and conversion disorder. The September 2017 VA examiner stated that depression could have aggravated tremors because VA treatment providers indicated the Veteran's tremors could be aggravated by a psychiatric disorder such as depression and/or the usage of duloxetine which could cause tremors. However, the June 2021 VA examiner believed the Veteran suffers from Parkinson's and the tremors may be secondary to nonservice-connected conversion disorder. The Board acknowledges the 2017 examiner's conclusion that the Veteran's service-connected depressive disorder and medication may have aggravated tremors, and Dr. S.S.'s 2011 note showing remote psychological issues such as depression, frustration due to back pain, anxiety, etc., can worsen or enhance tremors. However, the Board gives more probative weight to Dr. G.D.'s findings that the tremor was familial because the Veteran's mother and grandmother had similar tremors; the 2010 and 2011 diagnoses of Parkinson's Disease made at the Parkinson's Institute; VA treatment records showing the Veteran's mother's diagnosis of Parkinson's Disease and a significant family history of the illness including uncles and other distant relatives; a history of alcoholism; and the June 2021 VA examination report showing that the Veteran's tremors were caused by Parkinson's disease and secondary to nonservice-connected conversion disorder, and that the claimed disability was not caused or aggravated by a service-connected disability. The Board acknowledges the conflicting medical diagnoses, various medical reports and examinations, and the Veteran's frustration with his distressing medical condition; however, the probative evidence (including the opinion of several qualified examiners, physicians, and neurologists) does not support the Veteran's contentions. The Board has considered the Veteran's contentions and other supporting lay statements indicating a tremor disability is caused or aggravated by service and/or a service-connected disability. These statements in this case are not competent. The issue is medically complex, as it requires knowledge of pathology of a medically complex condition. As noted by the VA examiner, and evidenced by a plethora of private examinations and medical testing, tremors can have many different causes, thereby requiring medical expertise to determine the etiology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the June 2021 VA opinion and private and VA treatment records. Based on the foregoing, the Board denies the claim to service connection for tremors under all theories of entitlement. The preponderance of the evidence is against the claim. 4. Entitlement to service connection for a bilateral arm disability, to include bursitis, and other than cervical radiculopathy of the upper extremities and tremors, to include as secondary to service-connected disabilities is denied. The Veteran contends direct and/or secondary service connection for bilateral arm disability, to include bursitis, and other than cervical radiculopathy of the upper extremities and tremors is warranted. The Veteran was diagnosed with bilateral elbow bursitis and service treatment records indicate the Veteran suffered a back injury during INACDUTRA which resulted in arm and hand pain. A September 2017 VA examiner diagnosed the Veteran with bilateral elbow contracture. The Veteran reported no spontaneous complaints of elbow pain, however, the examiner noted bilateral mild limitation in extension associated with pain during passive range of motion testing. The examiner opined that the Veteran's elbow disability was less likely than not caused or aggravated by active service or a service-connected neck or back disability. He explained that the elbow condition is more consistent with chronic stiffness from Parkinson's disease which led to contracture of the elbow joint. The Veteran underwent a June 2021 VA examination. The examiner opined that the Veteran's disability was less likely than not caused or aggravated by active service or a service-connected disability. The examiner conducted an in-person examination, and reviewed the claims file, medical evidence, and lay statements. He explained that the Veteran's records do not support the Veteran's contentions and indicated he based his opinion on the Veteran's Parkinson's diagnosis in 2017, negative separation examinations. Moreover, the examiner stated that the medical evidence is not sufficient to establish a baseline severity nor was the evidence sufficient to determine whether the current severity of the bilateral elbow disability is aggravated beyond its natural progression by service-connected disabilities. Statements that are inconclusive as to the origin of a disorder generally cannot be employed as suggestive of a linkage between the disorder and the Veteran's military service. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). However, by the same token, these types of opinions also cannot be used to rule out this purported correlation, either. Ultimately, noncommittal opinions like this amount to nonevidence, neither for nor against the claim, because service connection may not be based on speculation or remote possibility. That said, the Court has cautioned that the Board should not rely on medical opinions that also were unable to establish this required linkage, without resorting to mere speculation, as cause for denying the Veteran's claims. See Jones v. Shinseki, 23 Vet. App. 382 (2010). In Jones, the Court noted it was unclear whether the examiners were unable to provide this requested definitive medical comment on etiology because they actually were unable to since the limits of medical knowledge had been exhausted or, instead, for example, needed further information to assist in making this determination (e.g., additional records and/or diagnostic studies) or other procurable and assembled data. The Court in Jones acknowledged there are instances where a definitive opinion cannot be provided because required information is missing or can no longer be obtained or current medical knowledge yields multiple possible etiologies with none more likely than not the cause of the claimed disability. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (noting the Board need not obtain further medical evidence where the medical evidence indicates that determining the cause is speculative). The Court in Jones held, however, that in order to rely upon a statement that an opinion cannot be provided without resort to mere speculation, it must be clear that the procurable and assembled data was fully considered and the basis for the opinion must be provided by the examiner or apparent upon a review of the record. Here, the 2021 expert reviewed the clinical evidence in its entirety, and following informed consideration, essentially opined that an opinion would require speculation. Rationale was provided for this finding. The expert explained that the evidence was not sufficient to establish a baseline severity nor was there sufficient information to determine whether the current severity of the bilateral elbow disability is aggravated beyond its natural progression by service-connected disabilities. The record does not contain any contradicting opinions. Furthermore, the September 2017 VA examiner believed the elbow disability was more consistent with chronic stiffness from Parkinson's disease which led to contracture of the elbow joint. In its February 2021 remand directives, the Board directed the RO to ask the Veteran to identify the bilateral shoulder disability, including specific symptoms he experiences, that he believes are part of his arm disability and that are separate from his service-connected disabilities. The Board has not received the requested information from the Veteran despite the record reflecting the RO contacted the Veteran on March 23, 2021, April 14, 2021, May 26, 2021, and May 27, 2021. The Veteran has a duty to assist and cooperate with VA in developing evidence; the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); see also Hayes v. Brown, 5 Vet. App. 60, 68 (1993) (VA's duty to assist is not a one-way street; if a veteran wishes help, he cannot passively wait for it in those circumstances where his own actions are essential in obtaining the putative evidence). The Veteran did not identify the bilateral shoulder disability, including specific symptoms he experiences, that he believes are part of his arm disability and that are separate from his service-connected disabilities. There is no duty to assist error as the Veteran did not submit any information noted in the 2021 remand directives despite receiving instructions on how to submit additional evidence in support of his claims. Despite the Veteran's failure to provide VA with medical provider information, the June 2021 VA examiner considered the Veteran's statements, the medical evidence of record, and the results of an in-person examination prior to rendering his opinion. Consideration has been given to the Veteran's contentions and other supporting lay statements that his disability is caused or aggravated by service and/or a service-connected disability. These statements in this case are not competent. The issue is medically complex, as it requires knowledge of pathology of a medically complex condition. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). While the Veteran is certainly competent to report that he experiences symptoms, he is not competent to link those complaints to a particular etiology. His assertions are therefore not competent evidence of a medical nexus. Accordingly, the Board finds that the claims of entitlement to service connection for bilateral arm disability, to include bursitis, and other than cervical radiculopathy of the upper extremities and tremors, to include as secondary to service-connected disabilities must be denied under any theory of entitlement. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to service connection, that doctrine is not applicable. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Entitlement to TDIU, generally A total rating for compensation 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. § 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(a). A Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. Age may not be considered as a factor in evaluating service-connected disability; and unemployability, in service-connected claims, associated with advancing age or intercurrent disability, may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high disability rating alone is a recognition that the impairment makes it difficult to obtain/keep employment. The question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). TDIU is to be awarded based on the judgment of the rating agency. Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). 5. Entitlement to TDIU from May 4, 2011 is dismissed as moot. In this case, the claim of entitlement to TDIU from May 4, 2011 has been rendered moot by the award of a 100 percent schedular evaluation for depressive disorder and SMC pursuant to 38 U.S.C. § 1114 (s). The United States Court of Appeals for Veterans Claims (Court) has recognized that a 100 percent rating under the Schedule for Rating Disabilities means that a Veteran is totally disabled. Holland v. Brown, 6 Vet. App. 443, 446 (1994), citing Swan v. Derwinski, 1 Vet. App. 20, 22 (1990). However, in Bradley v. Peake, 22 Vet. App. 280 (2008), the Court held that the issue of entitlement to TDIU may not be moot based on the assignment of a total schedular rating under certain circumstances, in particular where SMC could be awarded based on the consideration of a TDIU rating under 38 U.S.C. § 1114 (s). See also Buie v. Shinseki, 24 Vet. App. 242, 250-51 (2011). The Court's decision in Bradley recognizes that a separate award of a TDIU predicated on a single disability may form the basis for an award of SMC. As the Veteran is in receipt of a total (100 percent) rating, from May 4, 2011, there remains no time during this period where the schedular rating is less than total, as required for a TDIU and the AOJ has already awarded SMC pursuant to 38 U.S.C. § 1114 (s) during the entire period from May 4, 2011. Accordingly, the question of entitlement to a TDIU is dismissed as moot. 6. Entitlement to TDIU prior to May 4, 2011 is denied. Prior to May 4, 2011 the Veteran was service connected for residuals back injury (40 percent), degenerative arthritis of the cervical spine (20 percent), right and left shoulder strain, right and left upper extremity cervical radiculopathy (20 percent), and tension headaches (0 percent). He meets the schedular percentage requirement for consideration of a TDIU under 38 C.F.R. § 4.16(a) based on his service-connected disabilities prior to May 4, 2011. Therefore, the remaining question is whether the Veteran was unable to secure or follow a substantially gainful occupation because of these disabilities prior to May 4, 2011. The Board finds the preponderance of the evidence shows the Veteran is not precluded from substantially gainful employment solely due to his service-connected disabilities. The record reflects the Veteran worked as a maintenance manager from 1997 to 2006. He has two years of college education and received training in vehicle maintenance, aviation mechanics and maintenance, and as an aviation electrician. An April 2007 VA examiner observed the Veteran walking with normal gait, good coordination and balance, and maintained balance with his eyes closed. The Veteran bent over and removed his shoes without complaints of pain and bent over until his fingertips were at the mid tibia level. The Veteran was given a 15 pound stack of papers to lift from waist to shoulder level ten times, which he did without pain. The examiner indicated that the back disability would not impact his usual occupation and did not affect routine daily activities. Records from the Social Security Administration show the Veteran alleged he was too disabled to work because of back and neck disabilities, headaches, hand and arm tremors, depression, poor memory, leg pain and weakness, high blood pressure, and a stroke in 2000. SSA Records (obtained April 16, 2015) at 74. The Veteran and a third party reported that he is unable to complete ADLs; lives with his wife; has difficulty bathing; is unable to cook, do chores, or write checks; is unable to finish what he starts, handle stress or changes to his routine; has poor balance, memory and concentration difficulties; and cannot walk greater than 40 or 50 feet without resting for up to 10 minutes. The Veteran's spouse stated that the Veteran is unable to hike, waterski, ride horses, engage in sports, or spend time with friends. A former co-worker of the Veteran indicated in a document received in September 2007 that the Veteran moved into a management position but as his back became worse, it was difficult for him to work in the clean room because the cold temperatures would aggravate his back, neck and legs. As noted in greater detail above, the Veteran has several severely debilitating physical disabilities that are not related to service. Treatment records show, prior to May 4, 2011, the Veteran suffered from several nonservice-connected disabilities such as mild essential tremors, Parkinson's Disease, chronic bilateral idiopathic neuropathic pain of the lower extremities, stroke, hypertension, hyperlipidemia, depression, and alcohol abuse. A February 2011 mental health note shows the Veteran reported increasing pain and tremors until he was forced to apply for disability and leave work. March 2011 neurology notes show the Veteran's nonservice-connected disabilities limited his ability to do many things, including buttoning clothes, tying shoelaces, shaving, eating, writing, and brushing his teeth. The Veteran suffered from full body stiffness, slowness of movement, increased alcohol tolerance and consumption, walking with a walker intermittently. The preponderance of the evidence is against a finding that, prior to May 4, 2011, the Veteran was precluded from obtaining and maintaining substantially gainful employment solely due to his service-connected disabilities. The evidence shows the Veteran has severe nonservice-connected physical disabilities that impaired his ability to obtain and maintain gainful employment, including tremors, Parkinson's Disease, depression, memory and concentration difficulties, lower extremity disorders, balance impairment and falling, hypertension, dizziness, vision problems, anxiety, and stroke. Regarding the statement from the Veteran's co-worker in September 2007, it is in direct contrast to the determination of functional limitation due to the Veteran's back disability by the VA examiner in April 2007 and the Board finds that objective testing done by the VA examiner to consider the Veteran's impairment to be more probative. In evaluating the Veteran's claim for a TDIU, the Board also recognizes that the Social Security Administration (SSA) has determined that the Veteran is disabled pursuant to SSA rules and regulations. Specifically, the record indicates that the Veteran was found disabled by SSA on May 17, 2006. Although disability determinations made by SSA may be pertinent to claims for VA benefits, they are not controlling for VA determinations. Murincsak v. Derwinski, 2 Vet. App. 363, 370 (1992). Despite some similarities between the two disability regimes, there are "significant differences in the definition of disability under the Social Security and VA systems." Id. In its determination, SSA considered the Veteran's history of nonservice-connected disorders of the nervous system, muscle spasms and pain of the lower extremities, and tremors in determining that he was disabled. The Board has considered the benefit of the doubt when making this determination. As the weight of the evidence is against the Veteran's appeal, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mohammad Mahmoudi, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.