Citation Nr: 21072192 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 17-62 602 DATE: December 2, 2021 ORDER 1. Entitlement to an increased disability rating in excess of 40 percent for lumbosacral strain with degenerative disc disease (lumbar spine disability) is denied 2. Entitlement to an increased disability rating for right lower extremity radiculopathy in excess of 10 percent prior to September 12, 2017 and in excess of 20 percent thereafter is denied. 3. Entitlement to a total disability rating for compensation due to individual unemployability based on service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. The lumbar spine disability, including functional impairment, has not been manifested by unfavorable ankylosis of the entire thoracolumbar spine. 2. Radiculopathy of the right lower extremity was not manifested by moderate incomplete paralysis of the sciatic nerve prior to September 12, 2017, or by moderately severe incomplete paralysis of the sciatic nerve thereafter. 3. The preponderance of the evidence is against a finding that the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 40 percent for the lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code (DC) 5242-5237. 2. The criteria for a disability rating in excess of 10 percent for right lower extremity radiculopathy prior to September 12, 2017, and in excess of 20 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, DC 8520. 3. The criteria for a TDIU rating have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1974 to March 1994. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a July 2020 Board of Veterans' Appeals (Board) videoconference hearing. The Veteran's increased ratings claims were remanded by the Board in July 2020 in order to obtain an updated VA examination relating to the Veteran's spine disability. During the pendency of the appeal, a November 2017 rating decision granted an increased 20 percent disability rating for right lower extremity radiculopathy, effective September 12, 2017. The Veteran contends that the increased rating should have been effective in May 2015 when he filed his increased rating claim. The Veteran further contends that his lumbar spine disability warrants an increased disability rating in excess of 40 percent. Additionally, a claim for a TDIU rating had been reasonably raised by the record in conjunction with the increased rating claim for the Veteran's lumbar spine disability. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In a VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability, received in June 2021, the Veteran contended that he is unable to secure or follow a substantially gainful occupation as a result of the service-connected lumbar spine disability since March 2018. Thus, the claim of entitlement to a TDIU rating is before the Board. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21, 4.40, 4.45, 4.59. The Rating Schedule is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). 1. Lumbar spine disability The Veteran's service-connected lumbar spine disability is currently rated as 40 percent disabling under DC 5242-5237 of the General Rating Formula for Diseases and Injuries of the Spine. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. The General Rating Formula provides the following, in pertinent part: a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is warranted for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine, and a maximum schedular 100 percent disability rating is assigned for unfavorable ankylosis of the entire (thoracolumbar and cervical) spine. These ratings are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Following a review of the evidence of record, including as discussed below, the Board finds that the preponderance of evidence weighs against the Veteran's claim of entitlement to a disability rating in excess of 40 percent. The Veteran underwent a VA examination for assessment of his lumbar spine disability in July 2015. The Veteran was assessed with a lumbosacral strain with degenerative disc disease. He reported difficulty with lifting and bending. The Veteran's initial range of motion testing was normal in that he had 90 degrees of flexion and 30 degrees of extension, bilateral flexion, and bilateral rotation. The Veteran exhibited no additional loss of function on repetitive use testing. The Veteran recorded full strength on muscle testing and negative straight leg raise testing. The examiner documented the Veteran had moderate symptoms of pain and numbness in the right lower extremity relating to mild radiculopathy. There was an affirmative finding of no ankylosis of the spine. The Veteran reported occasional use of a back brace. As to the functional impact of the Veteran's condition, the examiner stated that the Veteran has difficulty with the prolonged sitting required in his job as a bus driver. The Veteran underwent another VA examination in September 2017. The Veteran reported flare-ups with radiating pain and stiffness, which cause difficulty with bending, lifting, and prolonged standing. On initial range of motion testing the Veteran recorded forward flexion to 60 degrees, extension to 20 degrees, and lateral flexion/rotation to 20 degrees bilaterally. The Veteran's range of motion was reduced by 5 degrees on repetitive use testing, and the examiner stated that pain and lack of endurance cause a 10-to-15-degree loss of range of motion during a flare-up and with repeated use over time. The Veteran recorded full strength and was found to have no muscle atrophy. The Veteran had normal reflexes and sensation except for some reduced sensation in the right lower extremity. The examiner documented the Veteran exhibited moderate intermittent pain, paresthesias and or dysesthesias, and numbness in the right lower extremity, which the examiner attributed to moderate radiculopathy. The examiner stated that the functional impact of the Veteran's back disability is back pain, stiffness, limited range of motion, and difficulty with heavy lifting, bending, prolonged walking or climbing stairs. The longitudinal record indicates that the Veteran's back condition remained relatively stable thereafter. Records from 2018 show that the Veteran maintained independence with his activities of personal care, and treatment notes reflect the Veteran to have a normal range of motion and full strength on musculoskeletal examination. The Veteran was seen for a routine follow-up appointment in May 2019. Musculoskeletal examination was negative for arthritis, joint pain, muscle cramps, and stiffness. The Veteran denied an MRI and neurosurgery consultation in relation to his low back pain. At his July 2020 Board hearing, the Veteran reported that his back locks up and he experiences reduced mobility, and severe pain, with numbness in his right leg. He stated that his pain medication is helpful and he uses a back brace and a cane. The Veteran underwent another VA examination in February 2021. In addition to the Veteran's history of strain and degenerative changes, the Veteran was assessed with spinal stenosis, spondylolisthesis, and bilateral lower extremity radiculopathy. These diagnoses were noted to be a progression of the Veteran's previous diagnosis. The Veteran reported experiencing flare-ups twice per month with sharp, radiating pain that makes him unable to perform household tasks. On initial range of motion testing, the Veteran recorded forward flexion to 40 degrees; extension to 12 degrees; right lateral flexion to 20 degrees; left lateral flexion to 15 degrees; right lateral rotation to 27 degrees; and left lateral rotation to 30 degrees. The Veteran did not have additional loss of function or range of motion after observed repetitive use. The examiner stated that pain causes functional loss with repeated use, estimated as forward flexion to 32 degrees; extension to 10 degrees; right lateral flexion to 17 degrees; left lateral flexion to 13 degrees; right lateral rotation to 25 degrees; and left lateral rotation to 35 degrees. The examiner also estimated that, on flare-up, pain and weakness result in forward flexion to 20 degrees; extension to 7 degrees; right lateral flexion to 12 degrees; left lateral flexion to 10 degrees; right lateral rotation to 20 degrees; and left lateral rotation to 20 degrees. The Veteran recorded full strength in the right lower extremity and in the left lower extremity with hip flexion, knee extension, and ankle plantar flexion. However, he had reduced strength in the left ankle with dorsiflexion, where he was documented to have 4/5 muscle strength, and great toe extension, where he was documented to have 3/5 muscle strength, with no muscle atrophy. He recorded normal reflexes and sensation, except some decreased sensation in the right lower extremity. Straight leg raise testing was negative, bilaterally. The Veteran had moderate symptoms of intermittent pain, paresthesias and/or dysesthesias, and numbness in the lower extremities relating to bilateral radiculopathy. The examiner documented the Veteran did not have ankylosis. The examiner stated that the Veteran would likely have difficulty performing a job which requires heavy lifting, prolonged walking, prolonged sitting, or prolonged standing. The Veteran underwent another VA examination of the spine in August 2021. The Veteran's diagnoses remained the same. He reported flare-ups several times per month lasting one to two days which make him unable to walk, sit, or stand for prolonged periods of time. On initial range of motion testing, the Veteran recorded forward flexion to 50 degrees; extension to 20 degrees; right lateral flexion to 10 degrees; left lateral flexion to 10 degrees; right lateral rotation to 15 degrees; and left lateral rotation to 15 degrees. The examiner indicated that pain, fatigability, weakness, lack of endurance, or incoordination did not result in significant functional loss or reduced range of motion with repeated use over time or on flare-up. The Veteran recorded full strength with both lower extremities and normal reflexes with some decreased sensation in the left lower extremity. The Veteran recorded mild symptoms of intermittent pain in the right lower extremity and moderate symptoms on the left; with mild paresthesias and/or dysesthesias and numbness in the left lower extremity, but none on the right. These findings were attributed to radiculopathy. The examiner stated that the Veteran's lumbar spine disability rendered the Veteran unable to sit, stand or walk for prolonged periods of time, and unable to perform yardwork. Considering the symptoms and limitations associated with the Veteran's lumbar spine disability, the preponderance of the evidence is against an award of increased rating in excess of 40 percent. Notably, the record does not document objective clinical findings of ankylosis to warrant an increased rating under DC 5242-5237. Recurrent range of motion testing on four, separate VA examinations from 2015 to 2021covering a six-year periodshowed the Veteran maintained range of motion in his back. Ankylosis contemplates no motion of the joint. As the preponderance of the evidence is against a finding of ankylosis, the facts do not establish entitlement to an initial rating in excess of 40 percent. The Board also notes that while the Veteran is receiving the maximum rating based on limitation of motion, the Board has nevertheless considered the impact of functional loss in the Veteran's lumbar spine due to flare-ups of pain, fatigability, incoordination, repeated use, lack of endurance, and weakness to determine if his functional loss was equivalent to ankylosis. 38 C.F.R. §§ 4.40, 4.45, 4.59; Sharp v. Shinseki, 29 Vet. App. 26 (2017); DeLuca v. Brown, 8. Vet. App. 206-07 (1995). In this case, the Veteran was found to have functional limitations resulting from fatigue, pain, flare-ups, lack of endurance, incoordination, weakness, or repeated use. However, while the Veteran experiences the aforementioned symptoms, overall, the evidence does not show that these symptoms result in additional and significant functional loss equivalent to unfavorable ankylosis, as the Veteran has maintained range of motion in his lumbar spine throughout the appeal period, even with flare-ups and repeated use. He has no muscle atrophy with almost full muscle strength and has remained capable of ambulation with the use of a cane. Such findings are against the Veteran's lumbar spine disability warranting an increased disability rating in excess of 40 percent. In sum, the preponderance of the evidence is against an increased rating in excess of 40 percent for the Veteran's lumbar spine disability. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran's claim for an increased rating for the lumbar spine disability is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 2. Right lower extremity radiculopathy The Veteran's radiculopathy of the right lower extremity is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, DC 8520, for paralysis of the sciatic nerve. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various DCs are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. However, the Board notes that a 60 percent rating under DC 8520 requires not only an assessment of "severe" incomplete paralysis, but also marked muscular atrophy. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against an increased rating for right lower extremity radiculopathy. The reasons follow. Prior to September 12, 2017 As discussed above, the Veteran underwent a VA examination in July 2015. The Veteran was found to have moderate symptoms of pain and numbness in the right lower extremity relating to mild radiculopathy. The Veteran was noted to have no other signs or symptoms of radiculopathy. The Veteran recorded full muscle strength and continued to work full time as a bus driver at this time. The Veteran continued to report back pain radiating into his legs thereafter. However, treatment records throughout 2016 show that the Veteran had normal examinations of the extremities with normal muscle tone and a normal gait. Examination findings from April 2016, September 2016, and August 2017 state that the Veteran had no numbness or weakness of any extremity. Treatment records do not show significant exacerbations of the Veteran's radiculopathy symptoms during this time. The Veteran remained independent in activities of daily living and did not require urgent or inpatient treatment. These findings are generally consistent with the July 2015 examiner's assessment of mild right lower extremity radiculopathy, which does not warrant a disability rating in excess of 10 percent, pursuant to DC 8520. To the extent that the Board is denying entitlement to a disability rating in excess of 10 percent, the Board notes specifically that the Veteran's reports of radiating pain have been considered in evaluating the Veteran's neurological manifestations. See 38 C.F.R. § 4.6 (Board must evaluate all of the evidence, to the end that its decisions are "equitable and just"). Although the Veteran reported pain when seen at his VA examinations, and generally contended pain in other VA treatment records, the Veteran was found to have a negative straight leg test result and full strength on the right side when examined in July 2015. The Veteran had some reduced sensation and reflexes, but treatment records have indicated intact neurological functioning without numbness or weakness in the extremity. Despite reports of intermittent pain and numbness, the Veteran maintained a normal gait and independence in his daily affairs. The Board affords the clinical findings documented in the July 2015 VA examination report more probative value, as the examiners utilized medical testing, such as the straight leg test and sensory testing that covered from L2 to S1 of the lumbar spine and objective medical criteria to assess the Veteran's symptoms and found that the Veteran had mild symptoms of radiculopathy. The Veteran is in receipt of a 10 percent rating during this part of the appeal period, which contemplates mild incomplete paralysis of the sciatic nerve. Although the Veteran also reported pain on other occasions, these reports of pain do not constitute evidence of moderate incomplete paralysis of the Veteran's right lower extremity sciatic nerve for the appeal period. In sum, for all the reasons laid out above, the preponderance of the evidence is against entitlement to a disability rating in excess of 10 percent for Veteran's sciatic radiculopathy of the right lower extremity. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran's claim for an increased rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. From September 12, 2017 At the September 2017 VA examination, the Veteran exhibited moderate intermittent pain, paresthesias and or dysesthesias, and numbness in the right lower extremity. The Veteran recorded full strength and normal reflexes with some decreased sensation in the right lower extremity. The Veteran demonstrated a normal gait and was noted to require no assistive device. He appeared in no acute distress. The examiner found the Veteran to have moderate incomplete paralysis of the sciatic nerve in the right lower extremity. During treatment later in the same month, the Veteran's gross sensation was found to be intact in the Veteran's feet, and he recorded full strength in the extremities. Records from 2018 and 2019 document that the Veteran remained independent with his activities of personal care and treatment notes reflect the Veteran to have a normal range of motion and full strength on musculoskeletal examination. On VA examination in February 2021, the Veteran had moderate symptoms of intermittent pain, paresthesias and/or dysesthesias, and numbness in the lower extremities relating to bilateral radiculopathy. The Veteran was noted to have no other signs or symptoms of radiculopathy. He recorded full strength and normal reflexes on the right side with some decreased sensation. Straight leg raise testing was negative. On VA examination in August 2021, the Veteran was noted to have symptoms of only mild intermittent pain in the right lower extremity relating to radiculopathy with no numbness or paresthesias/dysesthesias. The Veteran recorded full strength and normal sensation and reflexes on the right side. The functional impact of the Veteran's bilateral lower extremity radiculopathy was stated to cause the Veteran to be unable to sit, stand, or walk for prolonged periods of time, and that he cannot do yardwork. The longitudinal evidence during the period at issue shows the Veteran's radiculopathy in the right lower extremity to be relatively stable and does not reveal findings of greater than moderate incomplete paralysis of the sciatic nerve in the right lower extremity. To the extent that the Board is denying entitlement to a disability rating in excess of 20 percent, the Board notes specifically that the Veteran's reports of radiating pain and numbness have been considered in evaluating the Veteran's neurological manifestations. See 38 C.F.R. § 4.6. Although the Veteran reported pain when seen at his VA examinations, and generally contended experiencing pain in other VA treatment records, the record shows that the Veteran's radiculopathy symptoms in the right lower extremity have actually improved during the relevant period, with the most recent examination findings showing the Veteran to have no more than mild intermittent pain with full strength, normal reflexes, and normal sensation. He has not required urgent or inpatient treatment relating to radicular symptoms. The Board affords the clinical findings documented in the VA examination reports more probative value, as the examiners utilized medical testing, such as the straight leg test and sensory testing that covered from L2 to S1 of the lumbar spine and objective medical criteria to assess the Veteran's symptoms and found that the Veteran's right lower extremity had no more than moderate symptoms associated with radiculopathy. The Veteran is in receipt of a 20 percent rating during this part of the appeal period, which contemplates moderate incomplete paralysis of the sciatic nerve. Although the Veteran has reported intermittent pain and numbness, these reports of pain do not constitute evidence of moderately severe incomplete paralysis of the Veteran's right lower extremity sciatic nerve for the appeal period. TDIU Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation because of service-connected disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, the disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and enough additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The Veteran is service-connected for lumbosacral strain with degenerative disc disease with a 40 percent disability rating from October 6, 2004; bone spur, resolved with metatarsalgia and hammer toe with a 20 percent disability rating from March 10, 2010; right lower extremity radiculopathy (sciatic nerve) with a 10 percent disability rating from May 14, 2015, and a 20 percent disability rating from September 12, 2017; left lower extremity radiculopathy (sciatic nerve) with a 10 percent disability rating from February 18, 2021, and a 20 percent disability rating from June 14, 2021;left lower extremity radiculopathy (femoral neve) with a 20 percent disability rating from June 14, 2021; skin rash, chest and back with a 10 percent disability rating from April 1, 1994; bilateral foot fungus/calluses with a 10 percent disability rating from April 1, 1994 obstructive lung disease with a noncompensable disability rating from April 1, 1994; hepatitis C with a noncompensable disability rating from November 24, 2004; and scar, status post bone spur removal, with a noncompensable disability rating from March 10, 2010. Based upon the above, the Veteran's combined disability rating was 70 percent from May 14, 2015, and 80 percent from February 18, 2021. As such, the Veteran has met the schedular criteria for a TDIU rating for the period on appeal. "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16. In determining whether a veteran can secure and follow a substantially gainful occupation, the United States Court of Appeals for Veterans Claims (Court) in Ray v. Wilkie directed the Board to consider the following factors: (1) the veteran's history, education, skill, and training; (2) whether the veteran has the physical ability (both exertional and non-exertional) to perform the type of activities required by the occupation at issue; and (3) whether the veteran has the mental ability to perform the activities required by the occupation at issue. 31 Vet. App. 58, 73 (2019). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The responsibility for making the ultimate TDIU determination is placed on the adjudicator and not a medical examiner. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). A medical examiner's role is limited to describing the effects of disability upon the person's ordinary activity. See Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The Veteran is competent to testify as to facts he personally observed or described; this includes recalling what he personally felt, saw, smelled, heard, or tasted. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Initially, the Board notes that the Veteran received a Social Security Administration (SSA) disability decision dated in October 2018, which found that he is disabled and unable to sustain full-time employment due to his combined impairments effective in March 2018. Such a finding is not binding on determinations made by VA. VA and SSA use different definitions and standards for determining disability and SSA also considers limitations from all disabilities, versus considering disabilities that are related only to service or a service-connected disability. In this instance, SSA stated that the Veteran's primary diagnosis relating to his disability was a vascular insult to the brain, which appears to refer to a stroke suffered by the Veteran in March 2018. For example, within the SSA disability application, when asked why he had stopped working, the Veteran wrote, "I retired from my job in 2017 and then suffered a stroke in March 2018 that rendered me disabled." However, the Veteran is not service connected for a vascular insult to the brain or stroke. VA may consider limitations resulting only from service-connected disabilities. As such, while evidence associated with the Veteran's SSA claim is considered in the totality of the evidence, the SSA disability decision has no bearing on the Board's conclusions herein. The above discussions relating to the Veteran's increased rating claims are incorporated herein, to the extent relevant. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against a finding that the Veteran is unable to secure or follow substantially gainful employment due to his service-connected disabilities. The reasons follow. The Veteran underwent a VA examination of his feet in March 2018. He was assessed with hammer toes on the right foot. A right hallux bone spur removal surgery was noted to have occurred in 1993. The Veteran was found to have pain in his foot that interferes with locomotion and prolonged standing. The Veteran was noted not to require the use of an assistive device for locomotion. The functional impact of the Veteran's foot disability was documented to prevent the Veteran from prolonged standing, repetitive use of the foot, running, jumping, and extended ambulation. As noted above, the Veteran was treated for vertigo symptoms and balance issues in March 2018 and it was determined that he had experienced a cerebral infarction, for which he is not service connected. Accordingly, the Veteran's symptoms attributable to the cerebral infarction are not discussed herein. The Veteran had to undergo physical therapy for this condition thereafter. While the Veteran's symptoms were noted to include visual disturbances and an ataxic gait with the use of a cane, the Veteran's physical examination findings during neurological consult in August 2018 showed normal lung function, full strength, and intact musculoskeletal function with normal bulk and tone. The private examiner stated that he observed no residual impairment and that he did not know why it was necessary for the Veteran to use a cane. Additionally, the disabilities for which the Veteran is rated at a noncompensable level, including skin rash, bilateral foot funguses/calluses, obstructive lung disease, hepatitis C, and scar, have not been shown to cause the Veteran significant limitations and have required little or no treatment during the relevant period. Records submitted to SSA in July 2018 indicate that the Veteran continued to have no problem managing his own personal care. Routine examination findings in May 2019 showed normal pulmonary, musculoskeletal, and neurological findings. The Veteran has not required urgent or inpatient treatment since that time. The weight of the evidence is against a finding that the Veteran is precluded from substantially gainful employment due to the service-connected disabilities. Although the Veteran's symptoms, including pain, prevent the Veteran from sustained physical activity, the Veteran's treatment has been relatively conservative. The Veteran has remained independent in his activities of daily living and findings show that the Veteran has maintained full strength and intact neurological functioning. The SSA records suggest that the Veteran became too disabled to work due to a nonservice-connected stroke in March 2018, and not due to his service-connected disabilities. Regarding the Veteran's education, training, skills, and work history, the Veteran has reported that he is a high school graduate with two years of college experience. The Veteran worked as a medivac/medical corpsman during his two decades in the military. The Veteran also has over 23 years of work experience as a bus driver, as documented in the SSA disability application, where he wrote he had worked in this job from January 1994 to April 2017. He described his job as operating a 44 passenger bus, where he transported passengers to and from the airfield. He wrote he had to make sure the vehicle was maintained properly and would take it in for servicing that was needed. He also wrote that he attended required training courses. He stated that he last worked full time in April 2017, but became too disabled to work in March 2018. Coincidentally, the Veteran wrote the same date of March 24, 2018 on both the SSA application and the VA TDIU application as to when he stopped working. However, he wrote different reasons for why he stopped working in these two applications. For example, within the SSA application, he wrote the stroke rendered him disabled. Within the VA application, he wrote his "back" precluded substantially gainful employment. Regardless, overall, the Veteran's education and work experience demonstrate a capacity for learning, training, and adaptability that would not be hindered by his service-connected disabilities. These attributes would facilitate the Veteran's return to substantially gainful employment. As to the Veteran's physical ability to perform substantially gainful employment, the Veteran experiences pain and reduced mobility due to his service-connected disabilities. However, the Veteran continues to exhibit full strength in his lower extremities and is independent in matters of personal care. Examination findings indicate that he only occasionally requires the use of a cane. Accordingly, the totality of the evidence shows that the Veteran is capable of performing work at least at the sedentary exertional level, so long as he has the ability to change positions between sitting and standing for comfort, as needed, and can use a cane for brief periods of ambulation. The Department of Labor's Dictionary of Occupational Titles (DOT) defines sedentary work as exerting up to 10 pounds of force occasionally (i.e., up to one third of the time), and/or a negligible amount of force frequently (i.e., from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. According to DOT's definition, sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. The Board finds no prejudice to the Veteran in considering this definition for purposes of deciding the Veteran's claim. The longitudinal record indicates that the Veteran is capable of sedentary work with a sit/stand option and the use of a cane for ambulation. Accordingly, the weight of the evidence shows that the Veteran is physically capable of performing substantially gainful employment. As to the Veteran's mental ability to perform substantially gainful employment, the Veteran has no service-connected psychiatric disorder. The record does not show that the Veteran's service-connected abilities have impacted his cognitive functioning or communicative abilities. He has consistently demonstrated appropriate behavior and is generally described as cooperative with intact neurological and cognitive functioning. As the Veteran's service-connected disabilities do not cause him mental limitations, the weight of the evidence shows that he is mentally capable of performing substantially gainful employment. Based on the above assessments of the Veteran's physical and mental abilities with consideration of his education, training, skills, and work history, the Board finds that the Veteran is capable of work that would result in income at the level of substantially gainful employment. For example, the preponderance of the evidence is against a finding that the Veteran's service-connected disabilities preclude him from jobs that can be performed at home, such as a telemarketer, where the employee makes calls and reads a script, which does not require extensive training or experience, would require minimal exertional activity, and would allow the Veteran to sit or stand as needed. Similarly, a customer service agent interacts with customers to handle complaints, process orders, and answer questions. These positions can often be performed from home, with limited physical activity, and would allow the Veteran to sit or stand as needed. The Veteran is also qualified to work as an emergency dispatcher. This occupation primarily involves collecting information from emergency reports and relaying that information to emergency medical technicians, fire fighters, and/or police in the field. The Veteran's decades of past work as a medivac and a bus driver has given him familiarity and experience in emergency services and working with a dispatcher. This job would not require significant additional training for the Veteran, and could be performed primarily while seated, allowing the Veteran to switch positions as needed. The Board also finds the Veteran is capable of performing certain cashier positions, or work as a library, theater, or museum attendant, positions that would not be physically demanding and would allow the Veteran to change positions intermittently. The above occupations would allow for the use of a cane for any brief periods of ambulation. These examples are not exhaustive but are merely illustrative of potential occupations that the Veteran could perform. This is evidence against a finding that the Veteran is precluded from all forms of substantially gainful employment due to the service-connected disabilities. For all the reasons described above, the Board finds that the preponderance of the evidence is against a finding that the Veteran is precluded from all forms of substantially gainful employment due to service-connected disabilities and, therefore, is not entitled to a TDIU rating. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, entitlement to a TDIU rating is denied. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Wonderling, 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.