Citation Nr: 21072244 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 17-28 791 DATE: December 2, 2021 ORDER Entitlement to an initial rating higher than 10 percent for right knee degenerative arthritis from June 28, 2012, to December 20, 2019, and higher than 40 percent from December 21, 2019, is denied. Entitlement to an initial rating higher than 10 percent for left knee degenerative arthritis from June 28, 2012, to December 20, 2019, and higher than 50 percent from December 21, 2019, is denied. Entitlement to a rating higher than 10 percent for right knee instability, effective December 21, 2019, is denied. Entitlement to a rating higher than 10 percent for left knee instability, effective December 21, 2019, is denied. Entitlement to a rating higher than 30 percent for a gastrointestinal disorder, claimed as diverticulosis and diverticulitis, is denied. Entitlement to a compensable rating for hiatal hernia, gastroesophageal reflux disease (GERD), and Barrett's esophagus from June 28, 2012, to December 20, 2019, is denied. Entitlement to a rating of 30 percent, but no higher, for hiatal hernia, GERD, and Barrett's esophagus, from December 21, 2019, is granted. Entitlement to a 30 percent rating, but no higher, for hypothyroidism is granted. Entitlement to an initial 10 percent rating, but no higher, for residual scars, status post bilateral inguinal hernia repair, is granted. Entitlement to a total disability rating for individual unemployability (TDIU), from June 28, 2012, is granted. REMANDED Entitlement to service connection for right thigh nerve damage is remanded. REFERRED The March 2020 VA eye examiner found that the Veteran had dermatochalasis which was at least as likely as not caused by hypothyroidism. This issue has therefore been raised by the evidence, as well as the issue of entitlement to special monthly compensation under U.S.C. § 1114(s) based on having disabilities rated as totally disabling and a separate disability rated at 60 percent or higher. These issues are referred to the Agency of Original Jurisdiction (AOJ) for adjudication. FINDINGS OF FACT 1. From June 28, 2012, to December 20, 2019, the Veteran's right and left knee degenerative arthritis did not manifest with flexion limited to 45 degrees or extension limited to 10 degrees, and did not manifest with instability. 2. Since December 21, 2019, the Veteran's left knee was assigned the maximum rating for limitation of extension. His left knee did not manifest with flexion limited to 45 degrees. 3. Since December 21, 2019, the Veteran's right knee did not manifest with flexion limited to 45 degrees or flexion limited to 45 degrees. 4. Since December 21, 2019, the Veteran's right and left knee instability has never been found to be at least moderate, and he has not had a repaired or unrepaired complete or incomplete ligament tear or a surgically-repaired diagnosed condition involving the patellofemoral complex. 5. The Veteran's diverticulitis and diverticulosis manifests with constipation, abdominal distention, and abdominal pain. He has not had severe symptoms with numerous attacks a year, malnutrition, and health that is only fair during remissions, nor has he had definite partial obstruction shown by X-ray, with frequent and prolonged episodes of severe colic distension, nausea, or vomiting. 6. From June 28, 2012, to December 20, 2019, the Veteran's hiatal hernia, GERD, and Barrett's esophagus was largely resolved, with only occasional reflux and mild esophageal spasms. He did not have dysphagia, regurgitation, substernal or arm or shoulder pain, or moderate stricture of the esophagus, and the condition was not productive of considerable impairment of health. 7. Since December 21, 2019, the Veteran's hiatal hernia, GERD, and Barrett's esophagus has manifested by persistently recurrent epigastric distress, pyrosis, reflux, substernal pain, sleep disturbance caused by esophageal reflux 4 or more times a year, and nausea. It has not manifested with symptoms of dysphagia, material weight loss, hematemesis, melena, anemia. It is not productive of severe impairment of health, and it does not cause severe esophageal stricture, permitting liquids only. 8. The Veteran's hypothyroidism is manifested by cold intolerance, fatigability, and mental sluggishness. He has not had weight gain, muscular weakness, cardiovascular involvement, or mental disturbance (including dementia). His symptoms attributable to hypothyroidism, if separately rated, would not allow for a rating higher than 30 percent. 9. The Veteran has two residual scars from his inguinal hernia repair surgeries, and he has stated that they are painful. The medical evidence does not indicate that he has any scars that are unstable, that are deep or associated with underlying tissue damage, or that cover at least 144 square inches. 10. Since June 28, 2012, the Veteran's service-connected disabilities prevent him from obtaining and retaining substantially gainful employment consistent with his educational background and work experience. CONCLUSIONS OF LAW 1. From June 28, 2012, to December 20, 2019, the criteria for an initial rating higher than 10 percent for right knee degenerative arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5260, 5261. 2. From June 28, 2012, to December 20, 2019, the criteria for an initial rating higher than 10 percent for left knee degenerative arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5260, 5261. 3. Since December 21, 2019, the criteria for a rating higher than 40 percent for right knee degenerative arthritis based on limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5260, 5261. 4. Since December 21, 2019, the criteria for a rating higher than 50 percent for left knee degenerative arthritis based on limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5260, 5261. 5. Since December 21, 2019, the criteria for a rating higher than 10 percent for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2020), (2021). 6. Since December 21, 2019, the criteria for a rating higher than 10 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2020), (2021). 7. The criteria for a rating higher than 30 percent for a gastrointestinal disorder, diagnosed as diverticulosis and diverticulitis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.114, Diagnostic Codes 7301, 7319, 7323, 7327. 8. From June 28, 2012 to December 20, 2019, the criteria for a compensable rating for hiatal hernia, GERD, and Barrett's esophagus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.14, 4.113, 4.114, Diagnostic Code 7346. 9. Since December 21, 2019, the criteria for a rating of 30 percent, but no higher, for hiatal hernia, GERD, and Barrett's esophagus have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.14, 4.113, 4.114, Diagnostic Code 7346. 10. The criteria for a 30 percent rating, but no higher, for hypothyroidism have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.119, Diagnostic Code 7903 (2016), (2018). 11. The criteria for an initial 10 percent rating, but no higher, for post-operative inguinal hernia repair scars have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.118, Diagnostic Codes 7800-7805. 12. Since June 28, 2012, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1966 to May 1969, and from September 1983 to June 2006. This case comes to the Board of Veterans' Appeals (Board) from September 2013 and May 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office. These issues were previously remanded in March 2019 for further development. In a July 2020 rating decision, entitlement to service connection for right shoulder tendonitis, depressive disorder due to other medical conditions (claimed as chronic pain disorder), and erectile dysfunction was granted. As these are full grants of the benefits sought, these issues are no longer part of the current appeal. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Right and Left Knee Degenerative Arthritis The Veteran has requested higher initial ratings for his right and left knee disabilities. In a September 2013 rating decision, entitlement to service connection for degenerative arthritis of the bilateral knees was granted, and assigned a rating of 10 percent, effective June 28, 2012. In a June 2017 rating decision, this was revised to two separate 10 percent ratings, one for each knee, effective June 28, 2012. In a July 2020 rating decision, the Veteran's evaluation for the left knee was increased to 50 percent, and his evaluation for the right knee was increased to 40 percent, effective December 21, 2019. The Veteran was also assigned evaluations of 10 percent for right knee instability and 10 percent for left knee instability, effective December 21, 2019. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which 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. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). For VA purposes, a normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. A limitation of flexion of the leg allows for a 10 percent evaluation when it is limited to 45 degrees, a 20 percent evaluation when it is limited to 30 degrees, and a 30 percent evaluation when it is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A limitation of leg extension is evaluated as 10 percent disabling when extension is limited to 20 degrees, 20 percent disabling when extension is limited to 15 degrees, 30 percent disabling when extension is limited to 20 degrees, 40 percent is assigned when extension is limited to 30 degrees, and 50 percent is assigned when it is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. 50 percent is the highest rating available for limitation of motion of the knees. The rating criteria for musculoskeletal disorders under 38 C.F.R. § 4.71a were amended, effective February 7, 2021 [Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453-69 (November 30, 2020)]. The amendments did not alter the rating criteria for evaluating knee extension and flexion under Diagnostic Codes 5260 and 5261. Separate ratings for knee disabilities may be assigned for disability of the same joint if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04 (2004); 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14. Evaluations for knee impairment can also be assigned due to ankylosis, symptomatic removal of cartilage, dislocated semilunar cartilage, malunion/nonunion of the tibia and fibula, or genu recurvatum. The Veteran has not at any time during the appellate term been found to have these disorders; these diagnostic codes are therefore not applicable and will not be further discussed. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5262, 5263. Additionally, the Veteran's lateral instability has been separately rated, and is discussed below. Arthritis (degenerative joint disease) can also be assigned a primary evaluation under Diagnostic Code 5003. When the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each major joint or group of minor joints. 38 C.F.R. § 4.71a, Diagnostic Code 5003. In this case, the Veteran has already been assigned at least 10 percent or higher for the entire appeal period; this diagnostic code would not allow for any higher rating, and will not be further discussed. The Veteran attended a VA examination in July 2013. The Veteran reported that he had burning pain in his knees, and occasional sharp pains. There was no locking. He reported having flare ups that caused pain of varying degrees, and he said that he had pain with prolonged standing, sitting, walking, or stooping. Range of motion testing found right and left knee flexion to 140 degrees and extension to 0 degrees. There was no objective evidence of painful motion. The Veteran was able to perform repetitive use testing with no further loss of motion. There was no tenderness to palpation, and muscle strength and stability testing was normal. There was no history of recurrent patellar subluxation or dislocation, and no meniscal conditions. The Veteran next attended a VA examination in December 2019. The Veteran reported that his knee pain had worsened, and that he had flare ups that caused a worsening of pain and made it difficult to run, walk/stand for long periods of time, or climb ladders/stairs. Range of motion testing found right knee flexion to 120 degrees and extension to 30 degrees, and left knee flexion to 105 degrees and extension to 70 degrees. The Veteran was able to perform repetitive-use testing with no further loss of range of motion. The examiner found that the examination was medically consistent with the Veterans' statements describing functional loss with repetitive use over time and during flare ups, and the range of motions would be the same. There was crepitus, but no tenderness on palpation or pain with weight-bearing. The examiner wrote that the Veteran had no ankylosis, dislocated cartilage, locking, or removal of cartilage. There were no meniscal conditions. He also wrote that there was no recurrent subluxation, but there was slight lateral and medial instability, which a brace would usually help. The Veteran reported that he sometimes wore a knee brace on both knees. The Veteran's private treatment records do not include any range of motion findings for the knees, or other indications of symptoms which would allow for higher or additional ratings. In November 2017, the Veteran reported having bilateral knee pain and wearing a knee brace on the left. Physical examination found normal strength, no swelling or deformity, and tenderness on the left. Imaging found mild degenerative changes. The Board finds that prior to December 21, 2019, ratings higher than 10 percent for each knee are not warranted. At no time prior to December 21, 2019, was the Veteran found to have flexion limited to 45 degrees in either knee, or extension limited beyond 0 degrees, even when considering painful motion, repetitive motion, and flare ups. At the July 2013 VA examination, the Veteran had full range of motion of 0 to 140 degrees in both knees, and there was no reduction after repetitive motion. The Veteran reported having flare ups in his knees that caused pain, but did not indicate that they caused any decrease in his range of motion. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). In the absence of any indication that the Veteran's range of motion in his right and left knees was ever limited to flexion of 45 degrees or extension of 10 degrees, higher ratings cannot be assigned for this period. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. While the Veteran did report having pain and burning in his knees, this has been compensated by the assignment of 10 percent ratings for painful knee motion. The Veteran's knee pain has therefore been considered, and would not allow for any higher ratings than 10 percent for this period. The Board considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca and Mitchell, which address functional loss due to symptoms such as pain. However, there is no indication that the Veteran was prevented from flexing or extending his knees less than the full range of motion during this period, including after repetitive motion or during flare ups, and higher ratings for this period are not warranted. Since December 21, 2019, the date of the latest VA examination, the Veteran has been assigned increased ratings of 50 percent for the left knee and 40 percent for the right knee. At the December 2019 VA examination, the Veteran had left knee extension limited to 70 degrees, and therefore he has been assigned the maximum possible rating for limitation of extension in the left knee. The Veteran also has not been found to have ankylosis in his left knee. For the right knee, he had flexion limited to 30 percent, which warrants a 40 percent rating. There is no indication that he ever had extension limited to 45 degrees or more, and therefore a rating higher than 40 percent for the right knee is not warranted. He also did not have flexion limited to 45 degrees in either knee, so no separate rating based on limitation of flexion can be assigned. The Board has considered the Veteran's reports of having pain and painful motion in his knees, but does not find that this allows for any higher ratings than those already assigned. See 38 C.F.R. §§ 4.40, 4.45, 4.59. The December 2019 VA examiner did consider the Veteran's reports of flare ups and whether there would be any additional loss of function with repetitive use over time, but he found that the examination results were consistent with the Veteran's reports of functional loss with use or during flare ups, and no additional loss of range of motion would occur. Without any evidence indicating further functional limitation, the Board is unable to find that the Veteran's pain is so disabling as to actually or effectively limit flexion or extension of the knee to such an extent as to warrant assignment of any higher ratings. The Board acknowledges that effective dates should not be mechanically assigned based solely on the date of the VA examination, but should include consideration of all of the facts to determine the date that the increase in disability was ascertainable. See Swain v. McDonald, 27 Vet. App. 219, 224 (2015). In this case, while it is clear that the Veteran's knee disabilities must have undergone a substantial worsening at some point between the July 2013 VA examination and the December 2019 VA examination, the earliest date that it was ever demonstrated that the Veteran had extension limited to such an extent that ratings higher than 10 percent were warranted was at the December 2019 VA examination. There is no indication in the Veteran's treatment records of any worsening of the Veteran's knee range of motion prior to the December 2019 examination which would allow for a factual finding that the disabilities had increased in severity. December 21, 2019 is the first time that such a worsening was ever indicated, and it is therefore the appropriate date for the increased ratings of 40 and 50 percent. In sum, the Board finds that the preponderance of the evidence indicates that ratings higher than 10 percent for right or left knee degenerative arthritis, based on painful motion, from June 28, 2012, to December 20, 2019, is not warranted. Since December 21, 2019, ratings higher than 40 percent for right knee degenerative arthritis and higher than 50 percent for left knee degenerative arthritis, based on limitation of motion, are not warranted. The claims are denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine; however, the preponderance of the evidence is against any higher ratings. See 38 U.S.C. § 5107(b). Right and Left Knee Instability The Board is also unable to assign any ratings higher than 10 percent for his right and left knee instability. Under the regulations in effect at the time of the Veteran's initial claim, recurrent subluxation or lateral instability can be rated as slight (10 percent), moderate (20 percent), or severe (30 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5257. Terms such as "slight," "moderate," and "severe" are not defined in the rating schedule. Rather than applying a mechanical formula, VA must evaluate all the evidence so that its decisions are equitable and just. 38 C.F.R. § 4.6. Diagnostic Code 5257 was substantially revised in 2021. Under the revised regulations, a 10 percent rating is assigned when there is sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability; or there is a diagnosed condition involving the patellofemoral complex with recurrent instability; and without a prescription from a medical provider for an assistive device (cane, crutch, walker) or bracing for ambulation. A 20 percent rating is assigned when there is unrepaired or failed repair of complete ligament tear causing persistent instability, or there is sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability; or there is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair; and a medical provider prescribes either an assistive device (cane, crutch, walker) or bracing for ambulation. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). The Board has reviewed all of the evidence of record, but finds that at no time has the Veteran's right or left knee disabilities been found to be at least "moderate," and an initial rating higher than 10 percent is not warranted. There is no evidence indicating knee instability that was moderate or worse. The Veteran's joint stability testing found only the lowest level of medial and lateral instability, 0-5 millimeters. Anterior and posterior instability was normal. The VA examiner wrote that the Veteran's instability was "slight.," and that a knee brace would usually help. The examiner also found no instability of station. The Veteran sometimes wears braces for support, but he is able to walk normally, with no gait impairment or falls indicated by the evidence. The Board therefore finds that a rating higher than 10 percent for right knee instability under the prior version of Diagnostic Code 5257 (2020) is not warranted. A higher rating also cannot be assigned under the revised version of Diagnostic Code 5257 (2021). While the Veteran wears a brace for his knee, he has not been found to have a ligament sprain, incomplete ligament tear, or complete ligament tear. He has never undergone surgery for a ligament disorder or for a condition of the patellofemoral complex. The Board therefore finds that he does not meet the criteria for a higher rating under the revised regulations. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). The Board has considered the Veteran's lay statements, including that he needs braces for stability. The Veteran's assertions are credible and competent, but the Board does not find that these assertions are sufficient to indicate that his knee instability was moderate or severe, and do not allow for any higher rating. See Jandreau, 492 F.3d 1372, 1376-77. The Board also finds that the December 21, 2019 effective date for the start of the separate ratings for knee instability is appropriate. The December 2019 VA examination is the earliest date that it was factually ascertainable that the Veteran had any instability in either knee. See Swain, 27 Vet. App. at 224. At the July 2013 VA examination, joint stability testing was normal. The Veteran's private treatment records for the years between the July 2013 and the December 2019 VA examination show some complaints of knee pain, but not of any feelings of instability. In November 2017, the Veteran reported that he was wearing a knee brace on the left, and that he had knee pain, but he did not indicate having any instability. There are no other indications that the Veteran had symptoms of knee instability any earlier than the December 2019 VA examination, and therefore the date of this examination is the appropriate effective date for the start of these separate ratings. In sum, the Board finds that the Veteran does not have more than "slight" instability in his right and left knees, and he has not had a ligament sprain, incomplete ligament tear, or complete ligament tear. The Board therefore finds that initial ratings higher than 10 percent for right or left knee instability are not warranted. The Board has considered the benefit of the doubt doctrine, but the preponderance of the evidence is against finding that any higher ratings for knee instability are warranted. 38 U.S.C. § 5107(b). Gastrointestinal Disorders: Diverticulitis, Diverticulosis, Hiatal Hernia, GERD, and Barrett's Esophagus The Veteran has also requested a higher rating for his gastrointestinal disorders, which were previously characterized as "diverticulitis with hiatal hernia and GERD," and as "Barrett's esophagus." The Board notes at the outset that his gastrointestinal disorders appear to have been slightly mischaracterized by the Regional Office, as his hiatal hernia and GERD manifest with symptoms of reflux and heartburn, which are part of his Barrett's esophagus. The Veteran's diverticulitis, also diagnosed as diverticulosis, affects his bowel movements. The Board therefore finds that it was an error to group hiatal hernia and GERD together with diverticulitis. These issues have been recharacterized to better reflect their symptoms and the body systems affected. The Veteran wrote in June 2012 that he had been treated for a hiatal hernia in the military, which caused stomach pain, regurgitation, and throat burning, and led to Barrett's esophagus. He wrote that he also began to have referred pain in his shoulder and arm, and that he continues to have severe esophageal spasms, and some nausea, even with medication. He also wrote that he takes medication for gastritis and GERD, and that he has heartburn if he eats spicy food. Diverticulitis is rated under Diagnostic Code 7327. It is to be rated as irritable colon syndrome, peritoneal adhesions, or ulcerative colitis, depending upon the predominant disability pictures. 38 C.F.R. § 4.114, Diagnostic Code 7327. Irritable colon syndrome is assigned a 0 percent rating when it is mild, with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is assigned for moderate symptoms, with frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating is assigned for severe symptoms, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. Ulcerative colitis is assigned a 10 percent rating when it is moderate, with frequent exacerbations. A 30 percent rating is assigned when it is moderately severe, with frequent exacerbations. A 60 percent rating is assigned when it is severe, with numerous attacks a year and malnutrition, the health only fair during remissions. 38 C.F.R. § 4.114, Diagnostic Code 7323. Peritoneal adhesions are assigned a 0 percent rating when they are mild. A 10 percent rating is assigned when they are moderate, with pulling pain on attempting work or aggravated by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea), or abdominal distention. A 30 percent rating is assigned when they are moderately severe, with partial obstruction manifested by delayed barium meal and less frequent and less prolonged episodes of pain. A 50 percent rating is assigned for severe symptoms with definite partial obstruction shown by X-ray, with frequent and prolonged episodes of severe colic distension, nausea, or vomiting, following severe peritonitis, ruptured appendic, perforated ulcer, or operation with drainage. 38 C.F.R. § 4.114, Diagnostic Code 7301. The Veteran's private treatment records do not show any complaints of symptoms related to diverticulitis or diverticulosis. An August 2012 colonoscopy found diverticulosis in the sigmoid colon, non-bleeding internal hemorrhoids, and one 2 mm. polyp in the sigmoid colon. At a July 2013 VA examination, the Veteran reported that he had undergone 5 or 6 colonoscopies, with 2 or 3 polyp removals. He said that 20 years ago, he had diverticulitis and polyps, and now he watched his diet, including no fatty or rich food, and maintaining a high-fiber diet. The Veteran did not require medication. His only current signs or symptoms were constipation problems, for which the Veteran ate bran and sometimes took medication. He had frequent episodes of bowel disturbance with abdominal distress. He had 7 or more episodes of exacerbations or attacks of bloating and abdominal pain in the past 12 months. He had no weight loss or malnutrition. He reported that there were days when he was just so bloated, he did not do much activity until it passed. At a December 2019 VA examination, the Veteran reported having painless bleeding from his rectum, and that his colonoscopy had showed diverticulosis. He denied any infection. The Veteran took Metamucil. He had symptoms of constipation, abdominal distention, and cramping. The examiner found that the Veteran's symptoms were frequent episodes of bowel disturbance, 'There was no weight loss or malnutrition. The examiner noted that the Veteran had diverticulosis, not diverticulitis, as well as irritable bowel syndrome and a polyp. After reviewing the evidence related to the Veteran's diverticulitis and diverticulosis, the Board finds that a rating higher than 30 percent is not warranted. The Veteran's bowel disorder is primarily characterized by constipation, abdominal distention, abdominal pain, and cramping. He has reported that his symptoms are largely controlled through medication and diet. The Board finds that his predominant disability picture is most comparable to irritable colon disorder, as his symptoms do most closely match the symptoms of abdominal distress, constipation, and diarrhea which are listed under Diagnostic Code 7319. He has already been assigned the maximum rating, 30 percent, which can be assigned under 38 C.F.R. § 4.114, Diagnostic Code 7319. Even if the Board were to apply the rating criteria for ulcerative colitis or peritoneal adhesions, the Veteran would not meet the criteria for ratings higher than 30 percent. At no time have the Veteran's symptoms been described as "severe," and he has not ever been found to have malnutrition or that he has attacks which affect his overall health. The Veteran also does not have a definite partial obstruction shown by X-ray, and he has not had frequent and prolonged episodes of severe colic distension, nausea, or vomiting, following severe peritonitis, ruptured appendic, perforated ulcer, or operation with drainage. See 38 C.F.R. § 4.114, Diagnostic Codes 7301, 7323. The Board therefore finds that there are no other diagnostic codes which would allow for a rating higher than 30 percent. Regarding the Veteran's Barrett's esophagus, which has now been recharacterized as "hiatal hernia, GERD, and Barrett's esophagus," diseases of the digestive system are rated under 38 C.F.R. § 4.114. While GERD and Barrett's esophagus are not a disease specifically listed in the rating schedule, they are rated by an analogy to a listed disorder, based on the functions affected, anatomical localization, and symptomatology. 38 C.F.R. § 4.20. Hiatal hernia is listed and has its own rating criteria, under Diagnostic Code 7346, and the Board finds that the criteria does appropriately reflect the nature and symptomatology of the Veteran's digestive disorder. Under Diagnostic Code 7346, hiatal hernia is assigned a 10 percent rating with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is assigned when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating requires symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346. Although the schedular criteria for hiatal hernia do not specifically outline any criteria for a noncompensable (0 percent) rating, a 0 percent rating is assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. The Regional Office has previously applied Diagnostic Code 7203 to the Veteran's disorder. This rates stricture of the esophagus, and assigns a 30 percent rating when it is moderate. A 50 percent rating is assigned when it is severe, and permitting liquids only. 38 C.F.R. § 4.114, Diagnostic Code 7203. Spasm of the esophagus is listed separately, but if not amenable to dilation, is to be rated as stricture. 38 C.F.R. § 4.114, Diagnostic Code 7204. The Board notes that it finds that grouping these separating diagnoseshiatal hernia, GERD, and Barrett's esophagustogether under a single rating is appropriate, as his symptoms of epigastric distress, pyrosis, reflux, and substernal pain have been attributed to all of these disorders, which are related and affect the same body system. VA regulations specifically note that diseases of the digestive system, while differing in the site of pathology, produce a common disability picture characterized by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition. Consequently, these diseases do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle against pyramiding. 38 C.F.R. § 4.113. To assign separate evaluations would constitute impermissible pyramiding by assigning separate ratings for the same symptomatology. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Veteran's private treatment records show that in November 2013, the Veteran reported that his heartburn was resolved, and that the symptoms were relieved by Nexium. His associated symptoms included reflux. He denied chronic cough, dysphagia, dyspnea, melena, nausea, sore throat, vomiting, or weight loss. A December 2013 endoscopy found esophageal mucosal changes secondary to short-segment Barrett's disease, hiatus hernia, normal duodenum, and gastritis. In January 2014, it was found that the onset of his heartburn was long standing, but the problem was resolved. The symptoms were relieved by Nexium, and there was no chronic cough, dyspnea, melena, nausea, reflux, sore throat, or vomiting. His treatment providers wrote that his latest upper endoscopy did not show Barrett's esophagus, but that he should continue having an endoscopy every three years because of his past Barrett's. At a July 2013 VA examination, the Veteran reported that he took Nexium, with pretty good control, but sometimes he got esophageal spasms. He said that he avoided spicy foods and citrus. There were no other symptoms found, including episodes of epigastric distress, dysphagia, pyrosis, reflux, regurgitation, or substernal arm pain. The Veteran did have mild, intermittent esophageal spasms. The Veteran also attended a VA examination for esophageal conditions on December 21, 2019. The Veteran reported that he took daily medication, but had breakthrough heartburn and reflux. The examiner found that the Veteran had symptoms of persistently recurrent epigastric distress, pyrosis, reflux, substernal pain, sleep disturbance caused by esophageal reflux 4 or more times a year, and nausea. He also had mild esophageal stricture with mild spasms 2-3 times a day. After reviewing the evidence, the Board finds that prior to December 21, 2019, a compensable rating is not warranted. The Veteran reported on multiple occasions during this period that his stomach symptoms had resolved, and that while he had occasional heartburn, this was then stopped by taking another Nexium. The Veteran did not have any dysphagia, regurgitation, or substernal or arm or shoulder pain. While he had mild occasional esophageal spasms, at no time was he found to have actual stricture of the esophagus or any indication that he was at time prevented from eating or swallowing, and the Board therefore finds that these symptoms did not rise to the level of being "moderate." At no time during this period was it ever indicated that his symptoms were productive of considerable impairment of health. At the December 21, 2019, the VA examiner indicated that the Veteran had symptoms of persistently recurrent epigastric distress, pyrosis, reflux, substernal pain, sleep disturbance, and nausea. This indicates a significant worsening of the Veteran's symptoms, and does meet the criteria for a 30 percent rating under 38 C.F.R. § 4.114, Diagnostic Code 7346. A rating higher than 30 percent is not warranted, however, as there is no indication that the Veteran has ever had vomiting, material weight loss, hematemesis, melena, moderate anemia, or any other symptom combinations productive of severe impairment of health. The Veteran also has not been found to have stricture of the esophagus which allows for him to consume liquids only. The Board has considered the Veteran's lay assertions, but they are consistent with this rating, and he has never indicated that he has had any of the symptoms which would indicate that a higher rating was warranted. The Board again acknowledges that effective dates should not be mechanically assigned based on the date of the examination, but the December 21, 2019 VA examination is the earliest date that it is ascertainable that the Veteran had these symptoms which allow for a higher 30 percent rating. See Swain, 27 Vet. App. at 224. The prior VA examination and multiple private treatment records which occurred before this examination showed that the Veteran's symptoms had largely resolved, and therefore they do not indicate any date of worsening earlier than December 21, 2019. In sum, the criteria for a compensable rating for hiatal hernia, GERD, and Barrett's esophagus have not been met for the period from June 28, 2012, to December 20, 2019. Since December 21, 2019, the Veteran was found to have symptoms which allow for a higher 30 percent rating. The preponderance of the evidence is against finding that any rating higher than 30 percent is warranted. The Board has again considered the benefit of the doubt doctrine, but the preponderance of the evidence is against the assignment of any higher ratings. 38 U.S.C. § 5107(b). Hypothyroidism The Veteran wrote in June 2012 that he was diagnosed with hypothyroidism in service, after he had many months of fatigue and puffy eyes. He wrote that he had loss of strength, slow heart rate, and difficulty concentrating, and that his hair was dry and cracked. He wrote that he has been treated with Synthroid, but his lab tests have been very difficult to stabilize, and he has had to frequently go to the doctor. The Veteran wrote in September 2013 that he had fatigue, constipation, and was mentally sluggish due to his hypothyroidism. Hypothyroidism is rated under Diagnostic Code 7903. The rating criteria for hypothyroidism was recently changed. Because this change occurred during the course of the appeal, the Board will apply whichever rating criteria is most beneficial to the Veteran. Under the prior rating criteria within Diagnostic Code 7903, in effect before December 10, 2017, a 10 percent rating is assigned when there is fatigability or continuous medication required for control. A 30 percent rating is assigned for fatigability, constipation, and mental sluggishness. A 60 percent rating is assigned for muscular weakness, mental disturbance, and weight gain. 38 C.F.R. § 4.119, Diagnostic Code 7903 (2016). Under the new regulations, a 30 percent rating is assigned for hypothyroidism without myxedema. The evaluation is to continue for six months after the initial diagnosis, and thereafter, should be rated based on residuals of disease or medical treatment under the most appropriate diagnostic codes for those body systems. A 100 percent rating is assigned for hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to, hypotension, bradycardia, and pericardial effusion)), and mental disturbance (including, but not limited to, dementia, slowing of thought, and dementia). 38 C.F.R. § 4.119, Diagnostic Code 7903 (2018). After reviewing all of the evidence, the Board finds that a 30 percent rating for hypothyroidism can be assigned. The Veteran's private treatment records show that he takes regular medication and has continuing follow ups for his hypothyroidism. In October 2012, the Veteran reported fatigue and that his hands were really cold. In March 2012 and January 2013, he reported having fatigue and decreased motivation. In May 2016, the Veteran reported having intermittent muscle aches and feeling fatigued. It was found that his chronic constipation was controlled at that time and that his hypothyroidism was stable. At a July 2013 VA examination, the Veteran reported that his Synthroid dosage had to be changed all the time, and the levels were hard to regulate. He required continuous medication, but did not have radioactive iodine treatment or other treatment. The examiner did not find any current findings, signs, or symptoms attributable to the thyroid disorder. For eyes, he wrote that the Veteran had eyelid drooping. His pulse was regular and blood pressure was 135/84. The Veteran attended a VA examination in December 2019. The Veteran reported having breakthrough thyroid symptoms that required adjusting his medication dosage, and that he had scaly skin and intermittent fatigue. The examiner marked that the Veteran had gastrointestinal symptoms, reproductive symptoms, skin symptoms, eye involvement, and mental and psychological symptoms. He currently did not have cold intolerance, muscular weakness, or cardiovascular improvement, but did have mental sluggishness. The examiner concluded that the Veteran had fatigue, constipation, and/or mental sluggishness, and that the symptoms were mild with medication usage. The Board therefore finds that there is competent medical evidence that the Veteran has symptoms of fatigue, constipation, and/or mental sluggishness, and as such, a 30 percent rating is warranted under Diagnostic Code 7903 (2016). While the prior VA examiner did not find that the Veteran had these symptoms, the Board does find that in this situation, there is other evidence indicating that the Veteran had manifested these symptoms well before the December 2019, and therefore it would not be appropriate to limit the increased rating to a December 21, 2019 effective date. See Swain, 27 Vet. App. at 224. The Veteran's lay statements and private medical records show that he did report these symptoms on multiple occasions prior to December 2019, including in October 2012 and May 2016. The Board therefore finds that the 30 percent rating should be assigned for the entire period on appeal. The evidence does not indicate, however, that a rating higher than 30 percent is warranted. The Veteran has not been found to have muscular weakness, mental disturbance, and weight gain, which are the requirements for a higher rating under the prior regulations. See 38 C.F.R. § 4.119, Diagnostic Code 7903 (2016). Under the new regulations, because the appeal period is well after 6 months from the initial diagnosis, the condition is to be rated based on residuals of the disease or medical treatment under the most appropriate diagnostic codes for those body systems. 38 C.F.R. § 4.119, Diagnostic Code 7903 (2018). Regarding whether the Veteran's symptoms could be assigned higher ratings under separate diagnostic codes, the Veteran has already been assigned separate service connection for depressive disorder due to another medical condition, rated as 70 percent disabling. This rating is based on symptoms which include the effects of his hypothyroidism and other medical conditions, such as memory impairment, depressed mood, difficulty understand complex commands, intermittent inability to maintain hygiene, and intermittent inability to perform activities of daily living. The Board finds that these more extreme symptoms do encompass "mental sluggishness," and it would not be appropriate to therefore also assign him a separate rating for mental sluggishness under 38 C.F.R. § 4.130. The Board also acknowledges that the Veteran was found by the February 2020 VA examiner to have an eyelid disorder which is secondary to his hypothyroidism. This is a separate disability which has been referred, above, for adjudication. The Veteran's hands are often cold, but the Board does not find that this is, on its own, would allow for a compensable rating under any of the diagnostic codes. An unlisted condition may be rated under a closely related disease or injury in which the functions affected, anatomical localization, and symptomatology are closely analogous. 38 C.F.R. § 4.20. Even if the Board were to find that the Veteran's cold hands were analogous to a neurological impairment of the arms, there is no indication that he has had any functional impairment in his hands, nor has he indicated that he has any trouble moving or using his hands. Diagnostic Code 8515, which pertains to incomplete and complete paralysis of the median nerve, allows for only a 10 percent evaluation for each arm when the condition is mild. 38 C.F.R. § 4.124a, Diagnostic Code 8515. The Veteran also has intermittent constipation, but the evidence shows that this is generally controlled with medication, and there is no indication that he has had any of the symptoms of rectum impairment which would allow for a compensable rating under the schedule of ratings for the digestive system. See 38 C.F.R. § 4.114, Diagnostic Codes 7319-7334. The Board therefore finds that rating the Veteran's symptoms separately, as indicated by the revised regulation, would not allow for ratings which total more than 30 percent. The Board also finds that the higher 100 percent rating which is listed under the revised regulation cannot be assigned. While he has had cold intolerance, he has not had the other symptoms required for a 100 percent rating under the revised regulation, such as muscular weakness, cardiovascular involvement, and mental disturbance (including dementia), and the higher rating under Diagnostic Code 7903 (2018) is not warranted. In sum, the Board finds that the preponderance of the evidence indicates that the Veteran has had fatigability, cold intolerance, and constipation for the entire period on appeal. A 30 percent rating is warranted. He has not, however, had weight gain, muscular weakness, cardiovascular involvement, or mental disturbance (including dementia), and his hypothyroid symptoms, if separately rated, would not allow for a rating higher than 30 percent. Entitlement to a rating higher than 30 percent for hypothyroidism is therefore denied. The Board has again considered the doctrine of reasonable doubt; however, the preponderance of the evidence is against any higher rating. 38 U.S.C. § 5107(b). Residual Scars The Veteran contends that he had unsuccessful hernia surgeries in service, which have resulted in damage and chronic pain in his groin area, as well as pain and tenderness in 4 separate scars. The Veteran has submitted multiple statements indicated that his groin scars are painful to him. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118, Diagnostic Code 7804. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. Diagnostic Code 7805 states that any disabling effects not considered in a rating provision are to be evaluated under the appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7804 was not substantially changed by the August 13, 2018, amendments. The Veteran's private treatment records show that he has complained of severe testicular pain since his hernia repair. At a July 2013 VA examination, the Veteran was found to have two "very faint barely discernable scar in the right and left groin area." The examiner indicated that the scars were not painful or unstable. The Veteran had 2 linear scars on the anterior trunk. One was 7 cm., and the other was 6 cm. At a separate VA examination for hernia residuals, the examiner found no scars related to the hernia disorder, but the Veteran also requested no physical examination. The Board finds that because the Veteran has credibly and consistently reported that his scars are painful, it will afford him the benefit of the doubt and finds that a 10 percent rating is warranted. The Board accepts these assertions even though it is very unclear whether it is the Veteran's scars which are painful, or whether this is part of his generalized groin pain which he has reported on multiple occasions. The preponderance of the evidence is, however, against the assignment of a rating in excess of 10 percent under Diagnostic Code 7804. The most probative evidence of record indicates that the Veteran has only 2 faint scars, and that he does not have three or four scars that are unstable or painful. The Board acknowledges that the Veteran has written that he has four scars, and that all of them are painful. While the Board accepts that the Veteran is competent to report feeling pain in the area where his hernia repair surgeries occurred, the Board finds that these assertions are outweighed by the medical evidence of record. The July 2013 VA examiner clearly found that the Veteran had two "very faint barely discernable scar in the right and left groin area" and provided measurements for them. The examiner did not find any additional scars related to the hernia surgery, nor is there any other probative medical evidence indicating that the Veteran has additional scars related to his hernia repair surgeries in service which have not been considered. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran's scars are not on his head, face, or neck, they are not deep and nonlinear, and they are not associated with underlying soft tissue damage. The scars also do not cover an area or areas of 144 square inches or greater. Therefore, Diagnostic Codes 7800 through 7802, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effects not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. To the extent that the Veteran has also reported pain and recurring problems with his hernias, the rating assigned to the Veteran's hernia disorder, separate from the surgical scars, is not part of the current appeal to the Board, and therefore may not be considered at this time. In conclusion, the Board finds that the preponderance of the evidence indicates that the Veteran has two scars that are residuals of his hernia repair surgery, and he has reported that that they are painful, which allows for a 10 percent initial rating. The preponderance of the most probative evidence is against finding that he has any scars that are unstable or that he has more than two scars, and a rating higher than 10 percent is not warranted. In denying such a rating, the Board again finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107. TDIU The Veteran has also requested a TDIU because he has been unable to work due to his service-connected disabilities. In September 2013, he submitted a VA 21-8940 Application for Increased Compensation Based on Unemployability. He wrote that he had last worked in May 2011, as a guidance counselor for the Department of Defense. The Veteran wrote in September 2013 that he last worked full time in June 2011, as a guidance counselor for the U.S. Army. He wrote that he had to resign from this position due to his inability to perform the physical and cognitive demands of the job. He wrote that he had trouble focusing on work and was not able to complete tasks efficiently and correctly, and that he had chronic pain, which was distracting and led to errors. He wrote that he did not believe that he could work in any type of job full time or part time due to his disabilities. He described how he had trouble with prolonged sitting and standing, had fatigue, and VA will grant a TDIU when the evidence shows that a veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. The current period on appeal extends from June 28, 2012, until the present. Since June 28, 2012, the Veteran has been service connected for depressive disorder (70 percent), sleep apnea (50 percent), left knee degenerative joint disease (10 percent), right knee degenerative joint disease (10 percent), plantar fasciitis (30 percent), diverticulitis nad diverticulosis (30 percent), right shoulder tendonitis (20 percent), lumbar spine degenerative disc disease (10 percent), hypothyroidism (10 percent), tinnitus (10 percent), hernia repair scars (10 percent), left ear hearing loss (0 percent), Barrett's esophagus with GERD and hiatal hernia (0 percent), hammer toes (0 percent), other scars (0 percent), hemorrhoids (0 percent), right ilioinguinal nerve paralysis of the right groin (0 percent), and erectile dysfunction (0 percent). He therefore had a total evaluation of 100 percent for the entire appeal period. While a 100 percent total evaluation can render the issue of entitlement to a TDIU moot, since the maximum schedular rating has already been assigned, the Court of Appeals for Veterans Claims held in Bradley v. Peake, 22 Vet. App. 280 that there could be a situation where a veteran has a schedular total rating for a particular service-connected disability, and could establish a TDIU rating for another service-connected disability in order to qualify for special monthly compensation under 38 U.S.C. § 1114(s) by having an "additional" disability of 60 percent or more. In this case, there is evidence indicating that the Veteran's physical disabilities have rendered him unemployable, and he has an additional psychiatric disability rated as 70 percent disabling. It is therefore possible that he will be eligible for special monthly compensation under 38 U.S.C. § 1114(s), and the Board therefore accepts that entitlement to a TDIU is not moot. Resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to a TDIU, from June 28, 2012, is warranted. The Veteran submitted a September 2013 evaluation from nurse practitioner G.U. She wrote that she had reviewed the Veteran's service treatment records, civilian medical records, and other statements, and she found that the Veteran's service-connected disabilities did prevent him from performing his usual vocation of a guidance counselor, as well as preventing him from full time sedentary or light work within other vocations. She explained that he had only completed high school and some college, but did not have any higher level degree, and that most of his adult life had been spend in the military, and following his military retirement, he worked in the same type of job as a civilian working for the Army. She noted that he did not have any other special skills or certificates. She went on to explain how his sleep apnea caused problems with cognitive functioning due to daytime fatigue and drowsiness, his plantar fasciitis and knee disorders affected his ability to stand or walk for prolonged periods, his gastrointestinal problems were distracting and would disrupt his work, and his lumbar spine disorder caused difficulty with lifting or stooping, and required him to frequently change positions and take breaks. She discussed his hypothyroidism, and how this also affected his cognitive functioning, and would lead to safety concerns for himself and others, because of these cognitive deficits. She wrote that the overall instability of his multiple service-connected disabilities caused him to be able to obtain or maintain gainful employment. The findings of the September 2013 evaluation are consistent with the other evidence of record, including the report of the December 2019 VA examiner, who wrote that the Veteran's fatigue from his thyroid, and pain and functional impairment from his knees, led to issue with his completing physical tasks at work. The Board finds that the September 2013 evaluation provides adequate probative medical evidence to establish that he has, as likely as not, been unable to obtain or maintain gainful employment due to his service-connected medical disabilities for the entire period on appeal. Her findings are reasonable consistent with the other medical evidence of record and the lay statements submitted by the Veteran. It shows that he has physical limitations and impairments affecting his ability to concentrate and perform complex cognitive activities which would prevent both physical and sedentary jobs. In sum, the Board finds that it is as likely as not that since June 28, 2012, the Veteran's service-connected disabilities prevented him from obtaining and retaining substantially gainful employment consistent with his educational background and work experience. The claim is granted. REASONS FOR REMAND Right Thigh Nerve Damage The Veteran contends that he has right thigh nerve damage that was caused by complications from his right hernia surgery. At a July 2013 VA examination, the Veteran reported having pain in his right groin area after his first hernia repair, but no nerve disorders were found. An April 2017 medical opinion found that the Veteran had ilioinguinal nerve entrapment, which could include pain in the groin, scrotum, and inner thigh. At an August 2019 VA examination of the hip and thighs, the Veteran reported having right hip problems that interfered with his walking gait, and having radiating pain in the right hip. The Veteran has already been granted service connection for right ilioinguinal nerve incomplete paralysis. The Veteran has, nevertheless, appealed this issue and contends that he also has a right thigh disorder in addition to the right ilioinguinal nerve paralysis. In a March 2019 Board remand, the Board explained that a clarifying VA opinion was needed to be obtained to address whether the Veteran also has hernia surgery residuals affecting his thigh that are separate from the already service-connected nerve disorder. Unfortunately, the Board failed to include this request in the Action Items section of its remand. The Veteran attended a VA examination in August 2019, but an opinion was only obtained regarding a right hip orthopedic disorder, and not regarding the right thigh nerve damage claim. This issue is therefore again remanded so that an appropriate medical opinion can be obtained regarding whether the Veteran has any right thigh nerve damage which is separate from his postoperative ilioinguinal nerve dysfunction or right postoperative external cutaneous nerve dysfunction. The matters are REMANDED for the following action: Obtain an addendum medical opinion to address the nature of the Veteran's claimed right thigh nerve damage. If the examiner finds that a VA examination must be conducted prior to providing an opinion, schedule such an examination. If feasible, the examination may be held via telehealth during social distancing restrictions, and an opinion can be provided based on other medical evidence of record. The examiner must be provided access to all files in Virtual VA/Legacy and VBMS. The examiner must specify in the report that these records have been reviewed. The examiner should then discuss whether the Veteran has any current right thigh nerve damage. If no right thigh nerve disorder is found, the examiner is asked to discuss the Veteran's past diagnoses of both ilioinguinal nerve dysfunction and postoperative external cutaneous nerve dysfunction. He/she should then discuss whether any current right thigh nerve disorder is the same as his already service-connected postoperative ilioinguinal nerve dysfunction, or whether it is a separate disorder with separate symptomatology. The Board notes that the Veteran was not yet granted service connection for cutaneous nerve dysfunction. A complete and fully explanatory rationale must be provided. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mary E. Rude, 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.