Citation Nr: 21074114 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 17-08 841 DATE: December 14, 2021 ORDER Entitlement to service connection for hypertension as secondary to service-connected disabilities is granted. Entitlement to an increased disability rating in excess of 10 percent for right knee chondromalacia is denied. Entitlement to an increased disability rating in excess of 10 percent for left knee chondromalacia is denied. Entitlement to a separate 10 percent rating for right lateral knee instability, effective March 3, 2016, is granted. Entitlement to a separate 10 percent rating for left lateral knee instability, effective March 3, 2016, is granted. Entitlement to a total disability rating due to individual unemployability (TDIU), effective March 3, 2016 is granted. REMANDED Entitlement to service connection for diabetes mellitus, to include as secondary to hypertension, is remanded. Entitlement to service connection for transient ischemic attacks (TIAs) and cerebrovascular accidents (CVAs), to include as secondary to hypertension, is remanded. FINDINGS OF FACT 1. Resolving all doubt in favor of the Veteran, the Veteran's hypertension is proximately due to his service-connected disabilities. 2. Throughout the course of the appeal, the Veteran's right knee chondromalacia has been manifested by full extension, with flexion limited to 125 degrees during flare-ups. 3. Throughout the course of the appeal, the Veteran's left knee chondromalacia has been manifested by normal extension, with flexion limited to 125 degrees during flare-ups. 4. Throughout the course of the appeal, the Veteran constantly used knee braces for patellar instability and his right knee "gives out" causing him to fall frequently. 5. Throughout the course of the appeal, the Veteran constantly used knee braces for patellar instability and his left knee "gives out" causing him to fall frequently. 6. From the date of claim seeking an increased rating for his service-connected knees as well as service connection for a psychiatric disorder, March 3, 2016, the Veteran's service-connected disabilities rendered him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension as secondary to the service-connected disabilities have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for a rating in excess of 10 percent for right knee chondromalacia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5260. 3. The criteria for a rating in excess of 10 percent rating for left knee chondromalacia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5260. 4. The criteria for a 10 percent rating, but no higher, for right slight knee instability, effective March 3, 2016, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5260 (2020). 5. The criteria for a 10 percent rating, but no higher, for left slight knee instability, effective March 3, 2016, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5260 (2020). 6. The criteria for a TDIU, effective March 3, 2016, have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1975 to October 1975. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In a January 2019 Board decision, claims for increased rating for bilateral chondromalacia of the knee, and service connection for hypertension, acquired psychiatric disorder, and diabetes mellitus were remanded for further development. In an August 3, 2020 rating decision, the RO granted service connection for major depressive disorder and assigned a 50 percent disability rating; representing a full grant of the benefit sought on appeal. The Board finds that there has been substantial compliance with the remand directives and the remaining claims are now appropriate for adjudicative action. Stegall v. West, 11 Vet. App. 268 (1998). The issue of entitlement to service connection for TIAs and CVAs is on appeal from an August 2018 rating decision, which was timely appealed to the Board. Additionally, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) stated that a claim for a TDIU due to service-connected disability is part and parcel of an initial adjudication of a claim or an increased rating claim when such claim is raised by the record. The medical evidence discussed below pertaining to the Veteran's knee disabilities suggests that the Veteran may be unable to obtain or maintain substantially gainful employment. In light of the Court's holding in Rice, the Board considers the TDIU claim as part of his pending increased rating claims and has accordingly listed the raised TDIU claim as an issue on appeal here. Service Connection for Hypertension The Veteran is seeking service connection for hypertension. He has generally asserted that he has hypertension related to service. He has also asserted that his hypertension is secondary to his service-connected disabilities. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Additionally, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury; or, for any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of nonservice-connected condition. 38 C.F.R. § 3.310 (a)-(b). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Initially, the Board notes that VA examinations and VA clinical records show a diagnosis of hypertension. Thus, the Veteran has a current disability. However, the preponderance of the evidence is against finding that his hypertension manifested in service, within one year of discharge from service, or is otherwise directly related to service. In this regard, service treatment records reflect that the Veteran's separation physical examination in September 1975, the Veteran had a blood pressure of 96/60. Beginning less two months after entering service in June 1975, the Veteran was on consecutive profiles for subpatellar crepitus and bilateral knee pain until he received a medical discharge. Post-service, private treatment records from Dr. R.D. from June 2009 through August 2010, approximately 34 years later, document a diagnosis of hypertension with bi-monthly blood pressure readings that are all within normal ranges below 120/80. Moreover, the Veteran underwent a VA examination in September 2019. The examiner found that hypertension was not related to service as the Veteran's hypertension was not diagnosed in service. Further, in June 2020, another VA medical opinion was obtained. The examiner again found that hypertension was not related to service and observed that by the Veteran's history, his hypertension did not commence until 1990, 15 years after leaving service, and there is not documentation of a confirmed diagnosis of hypertension until a 2009 progress note, 32 years after service. With respect to direct service connection, the examiner noted that there was no evidence that the Veteran was diagnosed with hypertension. The Veteran demonstrated low blood pressure of 96/60 upon service separation. Hospital discharge records from December 2009 indicate that a bilateral duplex carotid ultrasound showed a mild right common carotid artery plaque and magnetic resonance imaging scan (MRI) of the head without contrast showed chronic microvascular ischemia. At the earliest, his hypertension commenced in 1990, 15 years after exiting the Army. Therefore, the examiner concluded that the Veteran's hypertensive vascular disease and hypertension are less likely than not incurred in or caused during service. In sum, service treatment records are silent with respect to any complaints, findings or diagnoses of hypertension. Post-service treatment records do not document treatment for hypertension until many years after service, and well outside the presumptive period. Importantly, the Veteran has primarily asserted that his disability is secondary to his service-connected disabilities. As such, service connection is not warranted on a direct basis. Turning to the question of whether service connection is warranted on a secondary basis. The Board finds that the evidence is, at least, in relative equipoise. In this regard, in August 2018 a private physician, Dr. H. S., performed a records review and telephone interview with the Veteran. He concluded that the Veteran's chronic pain from his service-connected bilateral knee chondromalacia significantly and materially contributed to the Veterans' hypertension. As rationale, he noted that the Veteran endorsed daily constant pain from his bilateral knee symptoms, flare-ups of intense pain three days per week lasting up to 45 minutes. Despite Losartan and metoprolol prescriptions, the Veteran's blood pressure readings are intermittently elevated despite this aggressive medication regimen. The Veteran had been diagnosed with TIAs and a CVA. Dr. H.S. noted that medical research "associates" chronic pain with an increased risk of hypertension. Further, in a June 2020 private opinion, Dr. S.E., concluded that the Veteran's chronic pain from his service-connected bilateral knee chondromalacia and his significant depression contributed to and aggravated his hypertension. He cited that medical research associates chronic pain with an increased risk of hypertension and anxiety and depression are predictive of a later incidence of hypertension. The examiner noted "hypertension which remains uncontrolled in spite of an aggressive medication regimen." He cited the Veteran's physical disabilities and emotional state as contributing to and aggravating his hypertension. In contrast, the September 2019 and June 2020 VA examiners found that hypertension was not secondary to the Veteran's service-connected bilateral knee disabilities or tinnitus. As rationale the September 2019 VA examiner noted that there is no known medical relationship between chondromalacia and hypertension. Moreover, the June 2020 VA examiner further concluded that the Veteran's hypertension was not aggravated beyond its natural progression by chondromalacia of the left knee, chondromalacia of the right knee, or tinnitus as it would have manifested during service, or at least, much sooner than 1990. In addition, there is not a known pathophysiological mechanism for the aggravation of hypertension by chondromalacia or tinnitus. Further, the Veteran's hypertension had been well-controlled over the years without evidence of worsening. From November 2011 to June 2015, the highest blood pressure recorded in available treatment records was 126/86. The Veteran was only taking one medication, metoprolol, for his hypertension in September 2019. If the Veteran's hypertension has been aggravated beyond its natural progression, more than one medication would be expected to treat worsening symptoms. Thus, the examiner concluded that the Veteran's hypertension was less likely than not aggravated beyond its natural progression by the Veteran's service-connected disabilities of bilateral chondromalacia or tinnitus. The Board is thus faced with a conflicting record as to whether the Veteran's hypertension is secondary to his service-connected disabilities. All of the examiners have been identified as medical professionals, were aware of the Veteran's medical history, and offered rationales for their opinions. However, the Board finds it significant that the Veteran is now also service-connected for major depressive disorder and generalized anxiety disorder and neither of the VA examiners addressed whether the Veteran's hypertension is secondary to his psychiatric disorder. Importantly, the June 2020 private examiner found that the Veteran's depression and anxiety contributed to his hypertension and cited to medical research that found a nigher incident of hypertension with high or intermediate anxiety symptom scores. The examiner also discussed how the Veteran's chronic knee pain remained extremely stressful for him. Thus, when resolving the benefit of the doubt in favor of the Veteran, service connection is warranted for hypertension as secondary to the Veteran's service-connected disabilities. In reaching this conclusion, the Board finds that the evidence is in at least a state of equipoise. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Disability Ratings for Knee Disabilities The Veteran seeks higher ratings in excess of 10 percent for his service-connected right and left knee disabilities, diagnosed as chondromalacia. The Board observes that the schedular criteria for evaluating disabilities of the musculoskeletal system, including the knee joint, have undergone revision during the pendency of this appeal. Specifically, and as relevant to this case, revisions to Diagnostic Code 5003, 5010, and 5257 were made effective February 7, 2021. See 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). Prior to February 7, 2021, Diagnostic Code 5010, instructed the rater to rate traumatic arthritis as degenerative arthritis under Diagnostic Code 5003. Under the revised criteria, Diagnostic Code 5010 applies only to post-traumatic arthritis, which is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Under both the earlier and revised rating criteria, degenerative arthritis is rated under Diagnostic Code 5003. Under this code, arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined and not added, under Diagnostic Code 5003. For purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 (limitation of flexion) and 5261 (limitation of extension). For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71 , Plate II. The Rating Schedule provides for ratings of 0, 10, 20, or 30 percent where there is limitation of flexion of the leg to 60, 45, 30, or 15 degrees, respectively, and for ratings of 0, 10, 20, 30, 40, or 50 percent for limitation of extension of the leg to 5, 10, 15, 20, 30, or 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. VA's General Counsel has held that separate ratings are available for limitation of flexion and limitation of extension under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004). As it pertains to recurrent subluxation or instability of the knee, and as noted above, revisions to Diagnostic Code 5257 were made effective February 7, 2021. See 85 Fed. Reg. 76457 (Feb 7, 2021). Because these changes took effect during the pendency of the Veteran's appeal, both the former and revised criteria will be considered in evaluating the Veteran's service-connected right knee disability. However, application of the new criteria prior to the effective date of the amended regulation is not allowed. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); see also 38 U.S.C. § 5110 (g). Prior to February 7, 2021, instability of the knee was rated under Diagnostic Code 5257, which provided ratings of 10, 20, and 30 percent for recurrent subluxation or lateral instability of the knee, which is slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Effective February 7, 2021, Diagnostic Code 5257 provides ratings for both recurrent subluxation or instability of the knee and for patellar instability. As it pertains to recurrent subluxation or instability of the knee, Diagnostic Code 5257 provides a 10 percent rating for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. As it pertains to patellar instability of the knee, Diagnostic Code 5257 provides a 10 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: brace, cane, or walker. A 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). See DC 5257 (Effective February 7, 2021). Diagnostic Code 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5259 provides for a 10 percent rating for symptomatic removal of the semilunar cartilage. The Veteran is currently assigned a 10 percent rating each for right and left knee chondromalacia for the entire rating period on appeal. The Veteran maintains that higher ratings are warranted. The Veteran's currently assigned 10 percent ratings have been awarded based on painful motion of the knee joints. As the Veteran's range of knee motion in flexion, to include during repetitive use testing and with flare-ups, has been no worse than 100 degrees (right knee) and to 110 degrees (left knee), ratings in excess of 10 percent are not warranted under DC 5260. In this regard, the May 2016 VA knee examination report noted flexion limited to 130 degrees for the right knee and 125 degrees for the left knee with full extension; the September 2019 VA knee examination revealed decreased flexion with repetitive use over time and flare-ups of 125 degrees of flexion with full extension in both knees. Further, as noted in the 2016, and 2019 VA knee examination reports, the Veteran has been able to fully extend both knees; as such, higher or separate compensable ratings under Diagnostic Code 5261 are not warranted. The Board recognizes the Veteran's reports of continued bilateral knee pain and stiffness, as discussed in the VA examination reports dated in 2016, and 2019. The Board considered this knee pain, swelling and any additional limitations of motion due to pain, including difficulty with prolonged sitting, walking, running, kneeling, and bending. However, even considering additional limitation of motion or function of the knee due to pain or other symptoms such as weakness, fatigability, weakness, or incoordination, the evidence still does not show that the bilateral knee disability more nearly approximates the criteria for a higher rating. Repetitive-use testing during the VA examinations discussed above showed no significant decreased range of motion in either knee. See 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, supra. Moreover, there is no evidence of any knee ankylosis, dislocated semilunar cartilage, or malunion of the tibia and fibula to support higher or separate ratings under DCs 5256, 5258, or 5262. The Board next finds that, based on the evidence of record, the Veteran's right, and left knee disabilities, based on instability, warrant separate 10 percent ratings throughout the period on appeal. Throughout the course of the appeal, the Veteran has relied upon knee braces with swing through crutches or a wheelchair. Stability testing in the VA examinations during the period on appeal has consistently found no instability; however, the Veteran has reported that his knees are unstable. He noted during his 2016 and 2019 VA examinations that he constantly uses knee braces and that both knees "give out" causing him to fall 3 or 4 times a month. Diagnostic Code 5257 does not require objective medical evidence of lateral instability for a rating to be assigned. See English v. Wilkie, 30 Vet. App. 347 (2018). Because the Veteran has competently and credibly reported bilateral knee instability symptoms, the Board finds that separate 10 percent ratings are warranted for slight lateral instability for the rating period on appeal. The Veteran's knee instability is not more accurately described as moderate. The medical records do not specifically describe instability of the knee joints and VA examiners and private treatment records have consistently found that the knee joints are normal on all stability tests. The Board finds that knee instability that causes functional impairment but is undetectable on all forms of examination is best characterized as slight in nature. The Board has also considered whether higher ratings are warranted beginning February 7, 2021, and pursuant to the revised criteria for DC 5257. The Veteran has been shown to have flexion reduced at most to 110 degrees and has not been diagnosed with a sprain, incomplete ligament tear, or repaired complete ligament tear. Further, the Veteran's slight bilateral knee instability does not more nearly approximate "recurrent instability." As noted above, VA examiners have consistently found that the knee joints are normal on all stability tests. The Veteran's chondromalacia associated with his knees has also not required surgical repair. Accordingly, higher ratings for instability of the knee joints is not warranted under both the earlier and revised rating criteria. For these reasons, the Board finds that separate 10 percent ratings are warranted for slight lateral instability of the right and the left knees, effective the date of claim for an increased rating, March 3, 2016. The Board further finds that the weight of the evidence is against ratings in excess of 10 percent for painful motion associated with chondromalacia of the right or left knee. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7. Entitlement to a TDIU The Veteran filed a claim seeking increased ratings for his service-connected bilateral knee disabilities on March 3, 2016. As discussed above, the Board finds that a claim for TDIU has been raised by the evidence of record during the course of the appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). VA will grant a TDIU when the evidence shows that a veteran is precluded, by reason of his service-connected disabilities, from securing and following "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. § § 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The central inquiry is, "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16 (a). The Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected condition and advancing age, which would justify a total rating based on individual unemployability due solely to the service- connected conditions. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Marginal employment shall not be considered substantially gainful employment. Marginal employment generally shall be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (including but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a). In Ray v. Wilkie, 31. Vet. App. 58 (2019), the Court defined the term "unable to secure and follow a substantially gainful occupation" as having two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of: the Veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. Considering the pertinent evidence in light of the considerations delineated above, the Board finds, for the following reasons, that the Veteran's service-connected disabilities precluded all substantially gainful employment for which his education and occupational experience would have otherwise qualified him from March 3, 2016. As noted above, the Veteran's TDIU claim is on appeal as part and parcel of his appeal for service connection for major depressive disorder and his claim for increased ratings for chondromalacia of the left and right knees. Therefore, the claim period for the TDIU matter dates back to the March 3, 2016, effective the date of service connection for mental health disorder. Harper, 30 Vet. App. at 361-62. In July 2016, the Veteran appealed the denial of claim for a mental health disorder and the claim was granted in an August 3, 2020 rating decision. In addition, effective March 3, 2016, the Veteran was service connected for major depressive disorder associated with chondromalacia left knee at 50 percent, chondromalacia of the left and right knee at 10 percent each, and tinnitus at 10 percent for a combined evaluation of 70 percent. In June 2018, Dr. HH-G, psychologist, completed a psychiatric evaluation and residual functional capacity evaluation on the Veteran. She noted that lay statements of two friends of the Veteran. She determined that the Veteran had been married to his third wife for three years, is socially isolated and withdrawn. His wife handles the finances. His longest held and last job lasted 4 years ending in 1988. The Veteran served time in prison after service. He was seeing a VA psychiatrist. His present symptoms included depressed mood, variable concentration, difficulty establishing and maintaining relationships, difficulty adapting to stressful circumstances including work, disturbances of motivation and mood, mild memory loss and impairment of short and long-term memory. with a below average intellectual capabilities and fund of knowledge. He was vague and appeared suspicious and paranoid; the Veteran cried during the interview. The psychologist assessed his residual functional capacity as predicted to miss 3 or mor days a month due to mental problems, would leave early 3 or more days a month due to mental problems, would be unable to concentrate to complete simple repetitive task more than 3 days a month for an 8 hour day, and while subjected to normal pressures during the workday the Veteran would respond in an angry manner at least 3 times a month. She found that the Veteran had occupational and social impairment with deficiencies in most areas of work, school, family relations, judgment thinking or mood. Moreover, the September 2019 VA examination for the knees also observed that the Veteran's knee disabilities would impact his ability to work due to difficulty walking and standing. On September 8, 2020, the Veteran submitted a VA Form 21-8940. He noted that he is a high school graduate earning a welding certificate during one year of community college. His last full-time job was as a packer/customer return specialist in 1988. The Veteran asserted that all of his service-connected disabilities prevented him from securing and maintaining substantially gainful employment. In sum, when considering the totality of the functional impairment caused by his service-connected disabilities as described by the lay and medical evidence of record, as well as taking into consideration his work history, education and experience, and when resolving all doubt in his favor, the Veteran would be precluded from substantially gainful employment due to his service-connected disabilities. In conclusion, based on the analysis above, the Board concludes that the Veteran has been unemployable since March 3, 2016, the date of award of service connection for his psychiatric disorder, due to his service-connected disabilities. Thus, entitlement to a TDIU from March 3, 2016 is warranted. [CONTINED ON NEXT PAGE] REASONS FOR REMAND Entitlement to service connection for diabetes mellitus, to include as secondary to hypertension, is remanded. Entitlement to service connection for transient ischemic attacks (TIAs) and cerebrovascular accidents (CVAs), to include as secondary to hypertension, is remanded. As the Board has awarded service connection for hypertension herein, and the Veteran has asserted that these disabilities are secondary to his hypertension, these issues must be remanded to afford the Veteran with VA examinations with opinions. The matters are REMANDED for the following action: 1. Obtain any additional VA clinical records dated from April 2020 to the present. 2. Schedule the Veteran for a VA examination(s) with an appropriate examiner(s) to determine the etiology of his diabetes mellitus, TIAs and CVAs. The examiner(s) must review the claims file. With respect to diabetes mellitus, TIAs and CVAs, the examiner(s) must opine whether it is at least as likely as not that any such disability is proximately due to or aggravated (any incremental increase in disability or any additional impairment of earning capacity regardless of its permanence) by his service-connected hypertension. The examiner(s) must provide a detailed rationale to support the opinions. The examiner must address August 2018 and June 2020 private opinions. J.N. Moats Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Adams Hill, 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.