Citation Nr: 21071190 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 13-28 279A DATE: November 30, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for traumatic brain injury (TBI) is denied. Prior to April 7, 2016, entitlement to an initial 30 percent rating, but no higher, for headaches is granted, subject to the laws and regulations governing the payment of monetary benefits. As of April 7, 2016, entitlement to a rating in excess of 30 percent for headaches is denied. REMANDED Entitlement to a rating in excess of 10 percent prior to April 18, 2016, for fracture of the left femur, to include the propriety of a separate compensable rating for shortening of the left lower extremity as of August 13, 2009, and in excess of 20 percent thereafter for fracture of the left femur with shortening of the left lower extremity is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (hereinafter, TDIU) is remanded. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's TBI resulted in no more than level "1" impairment in any facet of cognitive impairment. 2. For the entire appeal period, the Veteran's headaches are manifested by characteristic prostrating attacks occurring on an average of once a month, without more severe manifestations that more nearly approximate frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for traumatic brain injury have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124A, Diagnostic Code 8045. 2. The criteria for an initial rating of 30 percent, but no higher, for headaches have been met for the entire appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.124A, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran honorably served on active duty from May 1983 to April 1986. He also had active service from November 1987 to June 1992, but he was discharged under other than honorable conditions. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in April 2010 by a Department of Veterans Affairs (VA) Regional Office. In April 2015, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In January 2016, the Board remanded the case, as well as the issues of entitlement to service connection for a low back disability and an acquired psychiatric disorder, for additional development. In rating decisions issued in September 2020 and October 2020, the Agency of Original Jurisdiction (AOJ), in pertinent part, awarded service connection for degenerative arthritis of the lumbar spine and persistent depressive disorder. As such constitute full grants of the benefits sought on appeal with respect to those issues, they are no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). Additionally, the September 2020 rating decision awarded an increased rating of 30 percent for the Veteran's headaches, effective April 7, 2016, and an increased rating of 20 percent for fracture of left femur with shortening of the left lower extremity, effective April 18, 2016. However, as such do not constitute complete grants of the benefits sought on appeal, the claims remain on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). According to the September 2020 rating decision, the AOJ also determined there was clear and unmistakable error in establishing service connection for shortening of the left lower extremity associated with fracture of left femur and, therefore, the former would now be evaluated in combination with the latter. Given such determination, the Board herein takes jurisdiction of the issue of an increased rating for shortening of the left lower extremity prior to April 18, 2016, as part and parcel of the appeal for an increased rating for fracture of left femur and characterizes the issue accordingly. Moreover, the Board notes the Veteran's submission, via his representative, of a VA Form 20-0995, Supplemental Claim, in September 2021, which identifies the issue of entitlement to a TDIU and the denial of such in the September 2020 rating decision. Notably, this type of claim is a proper submission within the VA modernized appeals system. Nevertheless, as the Veteran has not formally withdrawn the appeal of entitlement to a TDIU within the legacy system, and the Board properly took jurisdiction of such in the January 2016 Remand pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), the Board includes the issue herein. Furthermore, as the issue is remanded for additional development, the Veteran is not prejudiced by its inclusion herein. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. 1. Entitlement to an initial rating in excess of 10 percent for TBI. Throughout the pendency of the appeal, the Veteran's TBI is rated as 10 percent disabling pursuant to 38 C.F.R. § 4.124A, Diagnostic Code 8045. Diagnostic Code 8045 states that there are three main areas of dysfunction that may result from a TBI and have profound effects on functioning: cognitive (which is common in varying degrees after a traumatic brain injury), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124A, Diagnostic Code 8045. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions include goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. VA is to evaluate cognitive impairment under the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified." Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, should be evaluated under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified." However, VA is to separately evaluate any residual with a distinct diagnosis that may be evaluated under another Diagnostic Code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" table. In this respect, the Board notes the AOJ awarded a separate rating for headaches as secondary to the Veteran's TBI in the April 2010 rating decision. The table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" addresses 10 facets of a TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled "total." A 100 percent evaluation is assigned if "total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," the overall percentage evaluation is assigned based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. Diagnostic Code 8045, in pertinent part, contains the following notes: Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of a Traumatic Brain Injury Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4): The terms "mild," "moderate," and "severe" traumatic brain injury, which may appear in medical records, refer to a classification of a traumatic brain injury made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. Note (5): A veteran whose residuals of TBI are rated under a version of § 4.124A, Diagnostic Code 8045, in effect before October 23, 2008, may request review under Diagnostic Code 8045, irrespective of whether his or her disability has worsened since the last review. VA will review that veteran's disability rating to determine whether the veteran may be entitled to a higher disability rating under Diagnostic Code 8045. A request for review pursuant to this note will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review; however, in no case will the award be effective before October 23, 2008. For the purposes of determining the effective date of an increased rating awarded as a result of such review, VA will apply 38 C.F.R. § 3.114, if applicable. On VA examination in February 2010, the VA examiner associated only headaches, for which the Veteran is in receipt of a separate service connection award and rating, and sleep problems with the Veteran's service-connected TBI. The VA examiner also noted that the Veteran experienced dizziness or vertigo once a month, particularly when he stood up and when he had a headache. The Veteran also reported chronic back issues, tingling and numbness down the right side of his body, weakness of the left leg, and ringing in the ears, which the VA examiner did not directly attribute to his TBI. Additionally, the VA examiner noted the Veteran had no history of seizures, balance or coordination problems, autonomic dysfunction, fatigue, malaise, psychiatric symptoms, memory impairment or other cognitive symptoms, neurobehavioral changes, bowel or bladder problems, erectile dysfunction, speech or swallowing difficulty, decreased sense of taste or smell, endocrine dysfunction, or cranial nerve dysfunction. Physical examination revealed no findings of autonomic nervous system impairment, gait abnormalities, imbalance or tremors, muscle atrophy or loss of muscle tone, spasticity or rigidity, fasciculations, cranial nerve dysfunction, hearing problems, endocrine dysfunction, skin breakdown, vision problems, psychiatric manifestations, or other abnormalities. With respect to cognitive impairment and other residuals, the February 2010 VA examiner specifically noted the Veteran did not complain of impairment of memory, attention, concentration, or executive functions, his judgment was normal, and his social interaction was routinely appropriate. The Veteran was always oriented and had normal motor activity. Notably, the Veteran's visual spatial orientation was mildly impaired, in that he occasionally got lost in unfamiliar surroundings and had difficulty reading maps or following directions. The VA examiner also appears to have determined the Veteran had subjective symptoms that did not interfere with work, instrumental activities of daily living, or work, family, or other close relationships. Likewise, one or more neurobehavioral effects did not interfere with workplace interaction or social interaction, the Veteran's consciousness was normal, and he was able to communicate by and comprehend spoken and written language. The VA examiner concluded the Veteran's TBI did not impact usual daily activities but that occupational activities were impacted by decreased strength in the lower extremity and pain. However, the VA examiner specifically noted the Veteran's previous loss of his job was related to back problems. A computerized tomography scan of the head in 2012 was read as "normal." At the April 2015 Board hearing, the Veteran reported that his TBI agitated him because he was unable to function the way that he wanted and that his daily living was "put on hold" as a result. When asked for greater specificity, the Veteran asserted that physicians had diagnosed him with posttraumatic stress disorder, which impacted his ability to concentrate and hold down a job. On VA examination in April 2016, however, the Veteran did not present any complaints of impairment of memory, attention, concentration, or executive functions. His judgment was normal, his social interactions were routinely appropriate, and he was always oriented to person, time, place, and situation. The Veteran's motor activity, consciousness, and visual spatial orientation were normal, and he denied any subjective symptoms. According to the VA examiner, the Veteran did not have any neurobehavioral effects, and he was able to communicate by and comprehend spoken and written language. Notably, the VA physician determined the Veteran's only subjective symptoms and/or residuals attributable to a TBI were his headaches. Additionally, following psychiatric examination of the Veteran in April 2016, the same VA physician found the Veteran had no post-traumatic amnesia from the in-service injury based on the Veteran's recollection of the incident. In addition, the VA physician found it notable that the hospital records dated at the time of the incident described the head injury as "minor", without any subsequent or residual cognitive symptoms or complaints. The remaining medical evidence dated during the pendency of the appeal, which is comprised mainly of VA treatment records, does not reflect any additional symptomatology or greater level of impairment attributed to the Veteran's TBI. In fact, aside from the Veteran's headaches, the treatment records are devoid of complaints of and/or treatment for symptoms associated with his TBI. Based on the above, the Board finds the medical evidence, which takes into consideration the Veteran's lay statements as well as neurocognitive, objective testing, does not show a level 2, 3, or total impairment in at least one of the relevant facets of cognitive impairment under the rating criteria. Here, the February 2010 VA examination report reflects the highest level of impairment to be a level "1" in the visual spatial orientation facet of cognitive impairment. Additionally, the VA examiner found the Veteran's tinnitus, intermittent dizziness, and insomnia, the subjective symptoms reported exclusive of his separately service-connected headaches, would not interfere with work, instrumental activities of daily living, or relationships in order to meet the criteria for level "1" impairment. Furthermore, VA examination in April 2016 did not reveal any residuals attributable to the Veteran's TBI other than his service-connected headaches. In this case, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, or lack thereof, and described the manifestations of such disability in light of the rating criteria to be more persuasive than the Veteran's own reports regarding the severity of such disability. Moreover, the Veteran himself has not reported additional symptomatology associated with his TBI separate from his service-connected headaches and a reported diagnosis of a mental health disorder. With respect to the latter, the Veteran is in receipt of service connection for a diagnosed persistent depressive disorder, which medical professionals have specifically attributed to his degenerative arthritis of the lumbar spine and not his service-connected TBI. Consequently, a rating in excess of 10 percent for the Veteran's TBI is not warranted. 38 C.F.R. § 4.124A, Diagnostic Code 8045. 2. Entitlement to an initial compensable rating prior to April 7, 2016, and in excess of 30 percent thereafter for headaches. Throughout the pendency of the appeal, the Veteran's headaches are rated pursuant to Diagnostic Code 8100. 38 C.F.R. § 4.124A. Under Diagnostic Code 8100, a 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent is warranted for migraines with characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. The rating criteria do not define "prostrating;" nor has the United States Court of Appeals for Veterans Claims (Court). Cf. Fenderson, supra (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack). By way of reference, the Board notes that, according to Webster's New World Dictionary of American English, Third College Edition (1986), p.1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in Dorland's Illustrated Medical Dictionary 1367 (28th Ed. 1994), in which "prostration" is defined as "extreme exhaustion or powerlessness." Also, the term "productive of severe economic adaptability" has not been clearly defined by regulations. The Court has, however, explained that "productive of" for purposes of Diagnostic Code 8100 can either mean producing, or capable of producing. See Pierce v. Principi, 18 Vet. App. 440, 445 (2004). Thus, migraine headaches need not actually produce severe economic inadaptability to warrant a 50 percent rating under Diagnostic Code 8100. Id. at 445-46. Similarly, "economic inadaptability" does not equate to unemployability, as such would undermine the purpose of regulations pertaining to a total disability rating based on individual unemployability. Id. at 446; 38 C.F.R. § 4.16. The Board notes, however, that the migraine headaches must be, at a minimum, capable of producing severe economic inadaptability in order to meet the 50 percent criteria. In the instant case, the Veteran's headaches are currently rated as noncompensably disabling prior to April 7, 2016, and 30 percent disabling thereafter. Upon review, the Board finds the evidence shows that such disability was manifested by characteristic prostrating attacks occurring on an average of once a month throughout the appeal period and, as such, a rating of 30 percent, but no higher, is warranted for the entire pendency of the appeal. On VA examination in February 2010, the Veteran reported experiencing headaches at least once per week that could last for several hours and were occasionally associated with nausea, blurred vision, and photophobia. VA treatment records dated in January 2014 show complaints of headaches that were very severe and could last from 12 to 24 hours. Such headaches were associated with cramping pain in the neck as well as blurred vision, but the Veteran did not report any associated photophobia, phonophobia, nausea, or vomiting. In April 2014, the Veteran reported daily headaches, without relief. At the April 2015 Board hearing, the Veteran reported constant headaches that, at least once a month, became so severe that they affected his eyesight. On those occasions, he felt the effects of the headaches for as long as a day, had to take medication, and either rested or slept. However, an August 2015 VA treatment record indicates the Veteran denied headaches, while a September 2015 VA treatment record reflects his complaints of intermittent headaches over the past few weeks, similar to his symptoms in the past that resolved spontaneously. Additional VA treatment records dated in September 2015 show he reported headaches with vision changes and light sensitivity on occasion. In February 2016, he complained of headaches for a week and a history of associated symptoms "off and on for a while." An April 2016 VA examination report similarly reflects the Veteran's complaints of headaches "at least once per week", which were characterized by constant, pulsating or throbbing pain that worsened with physical activity. The Veteran also reported associated symptoms of nausea, vomiting, sensitivity to light and sound, and changes in vision, and he described the duration of his typical head pain as lasting less than one day. The VA examiner found the Veteran had characteristic prostrating attacks of headache pain that forced him to go to bed but, for rating purposes, not "very prostrating and prolonged attacks of pain productive of severe economic inadaptability." In this regard, the VA examiner specifically noted the Veteran's headaches affected his concentration and forced him to take time off from work approximately three times per month. A September 2019 VA treatment record, however, reflects the Veteran's denial of any headache symptoms. Here, the Board affords probative value to the Veteran's testimony regarding weekly headaches and prostrating attacks of headache pain approximately once per month throughout the pendency of the appeal. Additionally, the April 2016 VA examiner specifically found the Veteran's description of his headaches approximated characteristic prostrating attacks of headache pain once every month. In this regard, the Board finds the aforementioned medical evidence reflects symptomatology and functional impairment throughout the pendency of the appeal that is consistent with the April 2016 VA examiner's determination. Thus, the criteria for a 30 percent rating have been met for the entire appeal period. Nevertheless, the April 2016 VA examiner also concluded the Veteran did not have very prostrating and prolonged attacks of pain productive of severe economic inadaptability. In this respect, the record does not show, nor does the Veteran report, that his headaches and associated symptomatology forced him to miss, on average, more than three days a month of work. Thus, although the Veteran's headaches symptoms may have included occurrences of prostrating and prolonged pain, the Board finds the evidence does not show the severity of such was productive of severe economic inadaptability so as to warrant a rating in excess of 30 percent at any time during the pendency of the appeal. In conclusion, after reviewing the totality of the evidence, and with consideration of the Veteran's subjective reports of headache symptoms, the Board finds the evidence reflects characteristic prostrating attacks occurring on an average of once a month and, therefore, a rating of 30 percent is warranted for the entire appeal period. However, as the evidence does not demonstrate very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability at any time during the pendency of the appeal, a rating in excess of 30 percent for headaches is not warranted. In reaching the foregoing determination, the Board has considered the applicability of the benefit of the doubt doctrine and applied such in the award of the 30 percent rating prior to April 7, 2016. However, as the preponderance of the evidence is against the Veteran's claim for a rating in excess of 30 percent for his service-connected headaches, such is inapplicable, and that aspect of his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Other Considerations In making its determinations in this case, the Board has also carefully considered the Veteran's contentions with respect to the nature of his service-connected disabilities at issue and notes that his lay testimony is competent to describe certain symptoms associated with these disabilities. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability ratings that have been assigned. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disabilities at issue. As such, while the Board accepts the Veteran's testimony with regard to the matters that he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected disabilities at issue. The Board has also considered whether staged ratings under Hart, supra, and Fenderson, supra, are appropriate for the Veteran's service-connected disabilities on appeal herein; however, the Board finds the Veteran's symptomatology referable to his TBI and headaches have been stable throughout the period on appeal. Thus, assigning staged ratings for such disabilities is not warranted. Furthermore, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the rating claims decided herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent prior to April 18, 2016, for fracture of the left femur, to include the propriety of a separate compensable rating for shortening of the left lower extremity as of August 13, 2009, and in excess of 20 percent thereafter for fracture of the left femur with shortening of the left lower extremity is remanded. The Veteran contends the severity of his service-connected fracture of the left femur with shortening of the left lower extremity warrants ratings higher than those currently assigned. In this respect, VA treatment records dated in August 2020 reflect the Veteran's reports of pain in the left knee and left hip and his request for shoe inserts, a straight cane, and a heating pad to manage his symptoms. Moreover, additional treatment records dated that same month indicate the Veteran had been experiencing serious issues with his left leg for the past three to four months with symptoms of swelling, giving way, locking, and falls. Upon review, the Board finds this evidence suggests the symptomatology associated with the Veteran's fracture of the left femur with shortening of the left lower extremity may have increased in severity since the April 2016 VA examination, and as such, a remand is necessary in order to afford him an appropriate VA examination to assess the current nature and severity of such service-connected disability. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). 2. Entitlement to a TDIU is remanded. In the January 2016 Remand, the Board directed that the AOJ schedule the Veteran for a VA examination by a vocational specialist to assess the functional effects of his service-connected disabilities on his ability to secure and follow a substantially gainful occupation consistent with his education and occupational experience. In this respect, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held in Smith v. Shinseki, 647 F.3d. 1380 (Fed. Cir. 2011) that opinions from vocational experts may be necessary in some cases to address "whether a [V]eteran is qualified in education and experience for the type of job that he is medically fit to perform." Id. The Federal Circuit also noted VA retained discretion to determine whether a vocational expert is necessary. Id. According to an April 2016 General Medical Compensation Disability Benefits Questionnaire, however, the Veteran was not scheduled for an examination by a vocational rehabilitation specialist per the directive of the lead physician for VA's Compensation & Pension (C&P), who stated that such service was "not available" to C&P. The record confirms that the Veteran did not undergo such an examination. Moreover, the evidence does not include an opinion that addresses the functional effects of the Veteran's service-connected disabilities, in combination, on his ability to secure or follow a substantially gainful occupational consistent with his education and work history. Consequently, the Board finds additional remand is warranted to afford the Veteran an examination by a vocational specialist to ensure compliance with the Board's prior Remand directives and completeness of the record. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following actions: 1. Afford the Veteran an appropriate examination to address the current nature and severity of his service-connected fracture of the left femur with shortening of the left lower extremity. The record, to include a copy of this Remand, must be made available to the examiner, and all indicated tests and studies should be accomplished. The examiner should describe the nature and severity of all manifestations of the Veteran's fracture of the left femur with shortening of the left lower extremity, to include the functional effects associated with such disability. A rationale should be provided for any opinion offered. 2. Then, schedule the Veteran for a VA examination by a vocational specialist to assess the functional effects of his service-connected disabilities on his ability to secure and follow a substantially gainful occupation. The examiner is asked to discuss the functional effects that the Veteran's service-connected disabilities, alone and in combination, have on his ability to secure or follow a substantially gainful occupation consistent with his education and occupational experience. The examiner must specifically address the Veteran's statements but may not consider the Veteran's age or any non-service-connected disabilities. A complete rationale must be provided for any opinion offered. ROBERT C. SCHARNBERGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. M. Celli, 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.