Citation Nr: 21074486 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 10-19 543 DATE: December 15, 2021 ORDER Entitlement to a 20 percent disability rating for a right ankle strain with degenerative osteoarthritic changes (right ankle disability), is granted. A separate 20 percent disability rating for instability of the right ankle is granted. REMANDED Entitlement to service connection for a vestibular disorder, to include vertigo and dizziness, to include as secondary to service-connected bilateral hearing loss and/or tinnitus, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU), to include on an extraschedular basis, is remanded. FINDINGS OF FACT 1. The Veteran's right ankle disability has manifested in marked limitation of motion during the entire appeal period. 2. The Veteran's right ankle disability has manifested in moderate instability. CONCLUSIONS OF LAW 1. During the appeal period, the criteria for entitlement to a rating of 20 percent for a right ankle disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.71a, Diagnostic Code 5271. 2. During the appeal period, the criteria for a separate 10 percent disability rating for moderate right ankle instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.71a, Diagnostic Code 5262. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1968 to September 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of October 2008 and March 2009 by a Department of Veterans Affairs (VA) Regional Office. An October 2008 rating decision denied the Veteran's claim for service connection for vertigo and dizziness. A March 2009 rating decision increased the rating for right ankle strain with degenerative osteoarthritic changes with a scar to 10 percent disabling, effective October 6, 2008. The issues were six times before the Board. In May 2012, January 2014, March 2017, November 2019, November 2020, and April 2021, the issues of service connection for a vestibular disorder and a rating greater than 10 percent for a right ankle disability were remanded for further development. In November 2020, service connection for a vestibular disorder was again remanded, and the increased rating claim for the right ankle disability was denied. The Veteran appealed the November 2020 Board denial to the United States Court of Appeals for Veterans Claims (Court), and in June 2021, the Court granted the parties' Joint Motion for Partial Remand (JMPR) and vacated the Board's denial. The issue was then remanded to the Board for development consistent with the JMPR. In April 2021, the Board remanded the claim for service connection for vestibular disorder and a TDIU, to include on an extraschedular basis. The RO was mandated to obtain updated treatment records; obtain an addendum VA medical opinion regarding the Veteran's vestibular disorder, specifically addressing the Veteran's head injury of June 1971; provide a retrospective opinion regarding the impact of the Veteran's service-connected disabilities on his ability to work; and provide a functional assessment of the Veteran's service-connected disabilities and the occupational limitations associated with each of the service-connected conditions. Additional records have been associated with the claims file. In July 2021, retrospective opinions were obtained, addressing the impact of the Veteran's scar, tinnitus, hearing loss, and right knee disability on his employment. In this regard, there has been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Regarding the June 2021 supplemental examination for BVPP, the Board finds that the examination, as is explained below, is non-compliant with the Board's remand. Thus, there has not been substantial compliance in this regard. Id. 1. Entitlement to a 20 percent disability rating for a right ankle disability is granted. 2. A separate 20 percent disability rating for instability of the right ankle is granted. Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.20. Where there is a question as to which of two evaluations shall be applied under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the claimant. 38 C.F.R. § 4.3. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a competent source. Second, the Board must determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303 (2007). Third, the Board must weigh the probative value of the evidence considering the entirety of the record. The Veteran's right ankle disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5271. Under DC 5271, a 10 percent evaluation is warranted for moderate limitation of motion of the ankle. A 20 percent evaluation is assigned for marked limitation of motion of the ankle. Normal dorsiflexion is 20 degrees. Normal plantar flexion is 45 degrees. 38 C.F.R. § 4.71, Plate II. The rating schedule does not define the terms "moderate" or "marked," as used in DC 5271 to describe the degree of deformity of the ankle. Instead, adjudicators must evaluate all of the evidence and render a decision that is "equitable and just." 38 C.F.R. § 4.6. 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 and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also to be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. DeLuca v. Brown, 8 Vet. App. 202 (1995); 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. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised select Diagnostic Code "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during a claim or an appeal, the version more favorable to the Veteran will apply to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period before and from the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria before February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that are more favorable to the Veteran will be applied. As amended, DC 5271 defines moderate limitation as less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, and marked limitation as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. The RO indicated that it received the Veteran's claim for an increased rating on October 6, 2008. In a November 2008 statement, the Veteran reported worsening pain and swelling in the right ankle and his wearing of over-the-counter cushions and specialty made shoes. The Veteran's treatment records show continuous complaints of right ankle pain. For example, in July 2009, the record shows a complaint of severe/sharp/continuous pain and swelling in the right ankle. The Veteran rated the pain at a 10/10. A few days later, the Veteran again complained of swollen ankle and pain with weight-bearing. He rated the pain at a 7/10 and indicated that he was taking Ibuprofen and Motrin (with partial relief) to help with the pain and swelling. The clinician noted decreased range of motion (ROM) in the right ankle and tenderness on palpation. A right ankle sprain was assessed. At an August 2009 physical therapy evaluation, the Veteran rated right ankle pain at 1/10 and 10/10 with aggravating factors. He reported that he sprained his ankle in July while assuming a standing position, "in an everted position," and had been wearing an air cast since. He also reported working as a teacher and participating in standing, squatting, and kneeling activities 6 to 8 hours per day. The examiner assessed an eversion ankle sprain. The aggravating factors were prolonged standing, walking, and climbing. The easing factors were rest and pain medication. The ankle was noted to be tender to palpation at the anterior talofibular ligament. Peroneal weakness was noted. The gait was antalgic and without an assistive device. Active ROM testing showed plantar flexion limited to 30 degrees, dorsiflexion to 20 degrees, inversion to 10 degrees, and eversion at 5 degrees. Muscle strength testing revealed plantar flexion at 3+/5, dorsiflexion 4-/5, inversion 4-/5, and eversion 3/5. In a treatment note dated in September 2009, the Veteran reported increased edema to the right ankle secondary to prolonged standing. The Veteran also underwent multiple VA ankle examinations throughout the appeal period. At a VA examination in February 2009, the Veteran reported pain and weakness in his left ankle, occurring three times, weekly and lasting one hour. He rated the pain level from 1 to 10, with 10, the worst. He described the pain as burning, aching, and sharp. Pain was elicited by physical activity and relieved by rest. At the time of pain, he could function with medication. The Veteran also reported weakness, swelling, redness, giving away, lack of endurance, and fatiguability. The examiner noted no stiffness, heat, locking, or dislocation. The functional impairment, per the Veteran, was the inability to be on his feet for extended periods of time and loss of days from work. The examiner diagnosed past right ankle sprain, post-operative with a scar and degenerative osteoarthritic changes present, which was a progression of the previous diagnosis. The examiner noted that the Veteran's gait was within normal limits. Upon examination, there was no evidence of abnormal weight-bearing. The initial ROM testing for the right ankle showed dorsiflexion to 20 degrees, with objective evidence of painful motion at 15 degrees. Ankle plantar ended at 45 degrees, with objective evidence of painful motion at 30 degrees. The joint function was additionally limited by pain, fatigue, weakness, lack of endurance, and incoordination after repetitive use. The pain was deemed as having a major functional impact and limited the joint function by 5 degrees. The Veteran was noted to have localized tenderness, absent signs of edema, effusion, weakness, redness, heat, and guarding of movement and subluxation. The examiner noted that the Veteran's left ankle function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. He did not require an assistive device for ambulation. The examiner noted that the Veteran's right ankle disability in his daily activities was a significant limitation on his ability to stand or walk for extended periods of time or distance. The Veteran underwent a second VA ankle conditions examination in February 2014. He reported worsening right ankle pain with recurrent strains. He reported it was aggravated by standing and the occasional use of a cane because of the ankle. The Veteran reported a three hour limit with weight-bearing and an ambulatory limit of six blocks due to right ankle pain. The examiner diagnosed right ankle strain with degenerative changes and heel spur. The Veteran report that flare-ups impact the function of the ankle. Flares and repetitive use caused increased pain but no fatigue, incoordination, or further loss of ROM. His right ankle plantar flexion was 45 degrees or greater, with no objective evidence of painful motion. His dorsiflexion was 20 degrees or greater with no objective evidence of painful motion. Repetitive-use testing revealed that plantar flexion was 45 degrees or greater and dorsiflexion at 15 degrees or greater. The Veteran did not have additional limitations in the ROM of the ankle following repetitive-use testing. He, however, had functional loss and/or functional impairment of the right ankle, including interference with sitting, standing, and weight-bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The examiner noted that muscle strength testing was not applicable, nor was joint instability or ankylosis. No additional conditions were noted, including shin splints, stress fracture, Achilles tendonitis or Achilles tendon rupture, or talectomy. The examiner noted that the Veteran had a total right ankle joint replacement in 1976 but no arthroscopic or other ankle surgery. The Veteran had residual signs and/or symptoms due to arthroscopic or other ankle surgery, including recurrent strains and joint pain with degenerative changes. The examiner noted that the Veteran occasionally used a cane as an assisted device for the right ankle. Imaging studies showed degenerative or traumatic arthritis and degenerative arthritic changes in the right ankle and heel spurs. The examiner noted that the Veteran's ankle disability impacted his ability to work because of his limited ambulation six blocks and limited weight-bearing to three hours. In April 2017, the Veteran was afforded another VA ankle conditions examination. The Veteran reported current symptoms of occasional swelling, minor "electrical shocking" sensation upon palpation of lateral right ankle, pain upon exertion (rated as 7/10), and straining of the right ankle over an extended period of time. He took Tylenol and Ibuprofen over the counter for the pain. The examiner diagnosed lateral collateral ligament sprain and osteoarthritis of the right ankle. The Veteran did not report flare-ups of the right ankle. However, he described functional impairment of the joint with the inability to walk less than a mile before having pain in the ankle. ROM testing revealed dorsiflexion to 16 degrees and plantar flexion to 40 degrees. The ROM itself did not contribute to a functional loss. Pain was not noted on examination. There was no objective evidence of pain with weight-bearing, localized tenderness, pain on palpation or crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions. His dorsiflexion was noted to be 18 degrees; plantar flexion was 35 degrees. Weakness was noted as a factor that caused a functional loss. The examiner reported that the Veteran was not being examined immediately after repetitive use over time or during a flare-up. Nonetheless, the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-ups. Regarding whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or during flare-ups and a description of ROM, the examiner noted that he was unable to say without mere speculation. He explained that such was the case because the examination was not being conducted immediately after repetitive use over time over time and during a flare-up. Additional factors attributing to the right ankle disability included weakened movement (due to muscle injury, disease, or injury of peripheral nerves, divided or lengthened tendons, etc.) and disturbance of locomotion. Muscle strength testing of the plantar flexion was normal, 5/5. The dorsiflexion, however, was noted as 4/5, active movement against some resistance. There was a reduction in muscle strength, which was due to the diagnosed right ankle disability. Neither muscle atrophy nor ankylosis was reported. Ankle instability or dislocation was suspected in the right ankle. The examiner noted that the Anterior Drawer Test revealed that there was laxity compared with the other side. The Talar Test was negative. The examiner did not report that the Veteran had nor ever had "shin splints," stress fractures, Achilles tendonitis or Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy. The examiner noted that the Veteran had other pertinent physical findings, complications, conditions, signs, or symptoms related to any conditions listed in the diagnosis section above, including minor "electrical shocking" sensation upon palpation of the lateral right ankle. The examiner noted that the Veteran had a scar relating to his right ankle disability. The scar, however, was not painful, unstable, nor occupied a total area equal to or greater than 39 square cm. The scar was located on the lateral right ankle and measured 14 cm length x 0.5 cm width. The examiner noted that the Veteran occasionally used a cane as an assistive device as a normal mode of locomotion for his right ankle strain with degenerative osteoarthritis changes. The examiner noted that the Veteran's right ankle disability impacted his ability to work. He also noted that the Veteran should avoid employment where he must do extensive walking due to the ankle condition, and which will cause him to have to sit down often during an eight-hour shift. The examiner remarked that there was no objective evidence of pain on the non-weight bearing. The passive ROM testing was the same as the active ROM. There was no evidence of pain on passive ROM testing. Regarding the Correia v. McDonald criteria, there was no objective evidence of pain on non-weight bearing in the left ankle. Correia v. McDonald, 28 Vet. App. 158 (2016). The passive ROM testing was the same as the active ROM. As noted in the Board's March 2017 and November 2019 remands, the VA examinations for his right ankle in February 2014 and April 2017 were inadequate for evaluation purposes. Thus, the ROMs therein will not be considered in the analysis. In December 2019, the Veteran underwent another VA ankle conditions examination. The Veteran reported that the current symptoms of his disability included pain, off and on, depending on activities, i.e., prolonged walking, climbing a ladder, and or steps. The pain made it difficult to perform weight-bearing activities, especially over prolonged periods. He took Tylenol for the pain. The examiner diagnosed tendonitis, osteoarthritis of the right ankle, and post-operative scar, right ankle. The Veteran did not report flare-ups of the right ankle. However, he reported functional loss or functional impairment of the joint with the inability to mow the grass, pushing a lawnmower. He reported problems with climbing stairs and difficulties going down the stairs because of instability going up. He reported that he needed "to hold the rails." The ROM was noted as normal (dorsiflexion of 20 degrees, plantar flexion of 45 degrees). Pain with dorsiflexion and plantar flexion was noted on the exam but did not result in/cause functional loss. There was evidence of pain with weight-bearing and passive ROM. There was no evidence of pain on non-weight-bearing testing of the ankles. There was localized tenderness or pain on palpation in the lateral and medial ankle; the Achilles tendon was an 8/10 and related to the diagnosed condition. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions. There was no additional loss of function or ROM after three repetitions. The examiner reported that the Veteran was not being examined immediately after repetitive use over time. Nonetheless, the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Pain significantly limited functional ability with repeated use over a period of time. The examiner noted that there was no further ROM loss anticipated during these scenarios, only increased symptoms (pain, fatigability, etc.), and thus, no ROM estimate was warranted. The examination was not being conducted during a flare-up. The examiner noted that the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss during flare-ups. The examiner stated that neither pain, weakness, fatigability, or incoordination significantly limited functional ability with flare-ups. In terms of ROM, the examiner noted that the Veteran did not report flare-ups. There were no additional contributing factors to the disability. Muscle strength testing was normal and there was no ankylosis. Neither ankle instability nor dislocation was suspected in the right ankle. The examiner did not report that the Veteran had nor ever had "shin splints," stress fractures, malunion of calcaneus (os calcis) or talus (astragalus), or talectomy. He, however, noted Achilles tendonitis or Achilles tendon rupture with current symptoms of localized tenderness and pain to palpation. The examiner noted that the Veteran had a scar relating to his right ankle disability. The scar, however, was not painful, unstable, nor occupied a total area equal to or greater than 39 square cm. The scar was located on the lateral right ankle and measured 8 cm length x 0.2 cm width. The examiner noted that the Veteran did not use an assistive device as a normal mode of locomotion. The examiner noted that the Veteran's right ankle disability impacted his ability to work, for he had decreased ability in performing activities that required sitting, standing, walking, climbing, lifting, or bending, especially with repetitive or prolonged use/activity. Based on the evidence presented above, the Board finds that the Veteran's right ankle disability more closely approximates a 20 percent rating, for a marked limitation of motion, under the older regulations. Thus, the maximum, 20 percent disability rating is warranted during the appeal period. 38 C.F.R. § 4.71a, DC 5271. The Veteran's symptomatology includes the decreased ROM, pain, difficulty bending, functional loss and/or impairment due to lack of endurance, fatiguability, incoordination, weakness, and pain on movement, tenderness, giving away, antalgic gait, difficulty standing, climbing, and walking for long periods, and his taking of continuous over the counter medication to alleviate the pain and swelling. Regarding the taking of medication, the Board notes that during the appeal period, the Veteran reported taking Motrin and Ibuprofen to alleviate the symptoms of his ankle disability. The ameliorative effects of medications are not contemplated by DC 5271. Jones v. Shinseki, 26 Vet. App. 56 (2012); see also 38 C.F.R. § 4.71a. The criteria for next-higher 30 or 40 percent criteria, the maximum available, ankylosis of the right ankle is not met. 38 C.F.R. § 4.71a, DC 5270. Here, neither the lay nor medical evidence supports a finding that the Veteran has ankylosis. Although the Board herein found that he has marked limitation of motion, the medical evidence shows that he retains mobility in the ankle. Therefore, ankylosis is not present. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992) (indicating that ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable). As a result, the Board finds that a rating greater than 20 percent for a right ankle disability is not warranted. Id. As the Veteran is already in receipt of the schedular maximum for limitation of motion of the ankle, inquiry into the DeLuca factors is moot. DeLuca, 8 Vet. App. 202, 206 (1995). The Board also notes that consideration was afforded other potentially applicable diagnostic codes for the Veteran's right ankle disability. During the appeal period, there was no evidence of malunion of the os calcis or astragalus with marked deformity of astragalectomy. Therefore, separate ratings under DCs 5272, 5273, and 5274 are not for application. The Board notes the Veteran's painful post-operative scar associated with his right ankle disability. However, since the February 13, 2014 examination where it was noted to be painful, he has been compensated for the disability under DC 7804. During the period on appeal, the record shows evidence of moderate instability. Thus, for the entire appeal period, a 20 percent rating is also warranted. Instability is not contemplated by DC 5271. However, under DC 5262, separate ratings are warranted by analogy for an ankle disability based on instability. Under DC 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A 40 percent rating is warranted for nonunion of the tibia and fibula with loose motion, requiring a brace. 38 C.F.R. § 4.71a. In a November 2008 statement, the Veteran reported wearing over-the-counter cushions and specialty-made shoes to support his worsening right ankle. At his February 2009 examination, the Veteran reported weakness and giving away of the right ankle. In an August 2009 clinical visit, the Veteran reported wearing an air cast. Further, during the February 2014 and April 2017 VA examinations, the examiners noted the Veteran's occasional use of a cane. Notably, during the April 2017 examination, the examiner suspected right ankle instability or dislocation and found that per Anterior Drawer Test, there was laxity compared with the other side. Lastly, during the December 2019 examination, the Veteran reported instability going up the stairs and his need "to hold the rails." A higher than 20 percent rating is not warranted. The Board finds that the evidence does not show that the Veteran has malunion of the tibia and fibula, and no medical professional has described symptoms that are analogous to malunion of the tibia and fibula. Therefore, his instability with the use of a cane, the wearing of an air cast, and over-the-counter cushions and specialty made shoes is most accurately described as moderate, not marked. Additionally, even though he requires the above-said aids, they are to alleviate the pain and swelling and help with the instability. There is no indication of record that they are for nonunion of the tibia or fibula, and no medical professional has stated that his symptoms are similar to a nonunion of tibia and fibula with loose motion or damage to the ligaments. In sum, the Veteran's symptoms from his right ankle disability have met the criteria for a 20 percent rating during the appeal period, under DC 5271, and a 20 percent rating under DC 5262. The Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether they have been raised by the Veteran or his attorney, as required by Schafrath, 1 Vet. App. 589 (1991). REASONS FOR REMAND 1. Entitlement to service connection for a vestibular disorder, to include vertigo and dizziness, to include as secondary to service-connected bilateral hearing loss and/or tinnitus, is remanded. The Veteran contends that he has a vestibular disorder, to include vertigo and dizziness, that was incurred in service. In the alternative, he argues that his vestibular disorder is caused or aggravated by his bilateral hearing loss and/or tinnitus. The Veteran has been diagnosed on VA examination with paroxysmal positional vertigo. The Veteran's service treatment records (STRs) show a June 1971 report of head and neck injury resulting from a dive into shallow waters. A November 1973 Report of Medical History indicates that the Veteran endorsed dizziness and fainting spells. Post-service treatment records show that in September 1979 and March 1989, the Veteran marked yes to having "car, train, sea, or air sickness." In September 1979, August 1982, and February 1987 Reports of Medical History, the Veteran reported no "dizziness and fainting spells." The Veteran has been afforded numerous VA examinations, all of which have been found inadequate for adjudication purposes, including a most recent addendum opinion of June 2021. In the June 2021 opinion, the examiner failed to address the Veteran's June 1971 head injury as instructed, while noting that "[w]hen there is a known cause, BPPV is often associated with a minor to a severe blow to your head." Furthermore, as the Veteran's attorney has rightfully pointed out, the examiner neglected to address the medical research articles submitted in March 2021 in support of a traumatic brain injury (TBI), leaving one more susceptible to later development of vertigo. As the examination is deemed incomplete and additional treatise evidence has since been submitted, a new examination is warranted to determine the etiology of the Veteran's vestibular disorder. 2. Entitlement to TDIU is remanded. The Veteran contends that he is warranted a TDIU. Currently, the Veteran does not meet the schedular criteria for a TDIU. When the threshold criteria for consideration of a schedular TDIU are not met, the issue of entitlement to a TDIU may be submitted to the Director of the Compensation Service for extraschedular consideration where the Veteran is unable to secure or follow a substantially gainful occupation because of service-connected disabilities. 38 C.F.R. § 4.16 (b); Fanning v. Brown, 4 Vet. App. 22 (1993). The Board cannot assign an extraschedular rating in the first instance. Bagwell v. Brown, 9 Vet. App. 337 (1996). Here, the record as it stands is insufficient to determine whether the Veteran is unable to secure or follow a substantially gainful occupation because of service-connected disabilities. While the evidence shows that the Veteran was employed as a teacher, the February 2009 examiner noted that the functional impairment of his ankle disability was the inability to be on his feet for extended periods of time and loss of days from work. Absent from the record and pivotal to the issue is the Veteran's employment status/marginal or otherwise, during the appeal period, his educational/occupational background, and wages; all of which would be provided in a completed VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. Furthermore, the outcome of the readjudication of the Veteran's claim for service connection for a vestibular disorder may have a substantial effect on the merits of his claim for a TDIU. Thus, the claim for a TDIU is deemed inextricably intertwined and remanded with the underlying service connection claim. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are 'inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered); Tyrues v. Shinseki, 23 Vet. App. 166, 178 (2009). As the outcome of the vestibular claim may have an effect on the TDIU claim and the record does not contain a completed VA Form 21-8940, a remand is necessary. Accordingly, the matters are REMANDED for the following action: 1. Provide the Veteran (and his counsel) with a VA Form 21-8940 and employment verification forms and request that he complete and return the said forms to the RO. 2. Provide the Veteran's claims file to a qualified clinician so that a supplemental opinion may be obtained to determine the etiology of his vestibular disorder, to include vertigo and dizziness. A physical or telehealth examination of the Veteran is only required if deemed necessary by the clinician. The entire claims file and a copy of this remand must be made available to the clinician to review. Although an independent review of the claims file is required, the Board calls the clinician's attention to the following: a. STRs dated in June 1971 reporting a head and neck injury resulting from a dive into shallow waters. b. A November 1973 Report of Medical History noting the Veteran's report of having had dizziness and fainting spells. c. Reports of Medical History dated in September 1979 and March 1989, noting the Veteran marked yes to having "car, train, sea, or air sickness." d. Reports of Medical History dated in September 1979, August 1982, and February 1987 noting that the Veteran marked no to "dizziness and fainting spells." e. Articles: i. "Benign paroxysmal positional vertigo (BPPV)." Mayo Clinic Last accessed: March 8, 2021. https://www.mayoclinic.org/diseases-conditions/vertigo/symptoms-causes/syc20370055 ii. Delay in diagnosis and treatment of benign paroxysmal positional vertigo in current practice. Muhammad, Arshad; Abbas, Shujat; and Qureshi, Ishaq Ahmad; J Ayub Med Coll Abbottabad 25.1-2 (2013): 93-95. iii. Increased Risk of Benign Paroxysmal Positional Vertigo in Patients with a History of Sudden Sensory Neural Hearing Loss: A Longitudinal Follow-up Study Using National Sample Cohort, Otology & Neurotology 40.2 (2019), Lee, Sang-Yeon; Kong, Il Gyu, Oh, Dong-Jun; and Choi, Hyo Geun. The clinician is asked to address the following: a. Whether it is at least as likely as not (50 percent or greater probability) that vestibular disorder, to include vertigo and dizziness manifested during active service or is related to any incident therein, including a head and neck injury resulting from a dive into shallow waters. b. Whether it is at least as likely as not (50 percent or greater probability), that a vestibular disorder, to include vertigo and dizziness, is proximately caused by his service-connected bilateral hearing loss and/or tinnitus. c. Whether it is at least as likely as not (50 percent or greater probability), that a vestibular disorder, to include vertigo and dizziness, is aggravated by his service-connected bilateral hearing loss and/or tinnitus. The clinician is reminded that for a secondary service connection claim, a VA medical opinion should not combine causation and aggravation; separate findings and rationales should be provided for each one. Atencio v. O'Rourke, 30 Vet. App. 74, 90 (2018). The examiner must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resorting to speculation, the examiner must state this and provide a rationale for such a conclusion. 3. Then, if the completed VA Form 21-8940 and employment verification forms are returned and shows unemployability or marginal employment, refer the claim to the Director of the Compensation Service for consideration of the issue of entitlement to TDIU on an extraschedular, pursuant to 38 C.F.R. § 4.16 (b). 4. Then, review the claims file. If the directives specified in this remand have not been implemented, take proper corrective action before readjudication. Stegall, 11 Vet. App. 268 (1998). Roya Bahrami Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Stevens, 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.