Citation Nr: 21075274 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 16-33 719 DATE: December 20, 2021 ORDER Service connection for a right shoulder disability is denied. Service connection for a right elbow disability is denied. Service connection for degenerative arthritis of the cervical spine is denied. Service connection for degenerative arthritis of the lumbar spine is denied. Service connection for a bilateral upper extremity neurological disorder is denied. Service connection for a bilateral lower extremity neurological disorder is denied. Service connection for prostate cancer is denied. Special monthly compensation (SMC) based on the need for the regular aid and attendance of another person or housebound status is denied. A total disability rating due to individual unemployability (TDIU) as a result of service-connected disabilities is denied. Eligibility for financial assistance in the purchase of one automobile or other conveyance and automobile adaptive equipment, or automobile adaptive equipment only, is denied. REMANDED Service connection for a left knee disability, to include as secondary to the service-connected right knee disability, is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. FINDINGS OF FACT 1. The Veteran's right shoulder degenerative joint disease was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that the Veteran's right elbow lateral epicondylitis and olecranon calcific enthesopathy began during active service or is otherwise related to an in-service injury or disease. 3. The Veteran's degenerative arthritis of the cervical spine was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise related to an in-service injury or disease. 4. The Veteran's degenerative arthritis of the lumbar spine was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise related to an in-service injury or disease. 5. The preponderance of the evidence is against finding that the Veteran's diagnosed right carpal tunnel syndrome or a disability manifested by left upper extremity numbness began during active service or is otherwise related to an in-service injury or disease. 6. The preponderance of the evidence is against finding that the Veteran has had a bilateral lower extremity neurological disorder at any time during or approximate to the pendency of the claim. 7. The preponderance of the evidence is against finding that the Veteran's prostate cancer began during active service or is otherwise related to an in-service injury or disease. 8. At the time of this decision, service connection is in effect for hypertension, tinnitus, chronic obstructive pulmonary disease (COPD), and disabilities of the left shoulder, left elbow, right knee, and a right knee surgical scar. 9. The Veteran's service-connected disabilities do not render him so helpless as to need the regular aid and attendance of another person. He is not permanently housebound by reason of his service-connected disabilities, and he does not have a single service-connected disability rated as 100 percent with additional service-connected disability or disabilities independently ratable at 60 percent. 10. The Veteran is not unable to secure or follow a substantially gainful occupation due to his service-connected disabilities alone. 11. The Veteran's service-connected disabilities do not result in the physical loss or permanent loss of use of one or both hands or feet, permanent impairment of vision in both eyes of a severity specified by regulation, severe burn injury, or amyotrophic lateral sclerosis. 12. The Veteran does not have ankylosis of one or both knees or hips. CONCLUSIONS OF LAW 1. The criteria are not met to establish service connection for a right shoulder disability. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 2. The criteria are not met to establish service connection for a right elbow disability. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria are not met to establish service connection for a cervical spine disability. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 4. The criteria are not met to establish service connection for a lumbar spine disability. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 5. The criteria are not met to establish service connection for a bilateral upper extremity neurological disability. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria are not met to establish service connection for a bilateral lower extremity neurological disability. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria are not met to establish service connection for prostate cancer. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria are not met to establish special monthly compensation based on the Veteran's need for aid and attendance or housebound status. 38 U.S.C. §§ 501, 1114, 5107; 38 C.F.R. §§ 3.350, 3.352. 9. The criteria are not met to establish entitlement to a TDIU rating. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.16. 10. The criteria are not met to establish eligibility for financial assistance in the purchase of an automobile or other conveyance and/or automobile adaptive equipment. 38 U.S.C. §§ 3901, 3902, 5107; 38 C.F.R. §§ 3.102, 3.808. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from July 1984 to January 1988 and from April 2003 to September 2003 with additional service in the Navy Reserve. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions in June 2015, March 2016, and January 2017. This appeal was last before the Board in May 2021 at which time additional evidentiary development was requested to comply with due process requirements. Except for the issues again remanded for additional development below, the evidentiary record has been adequately developed in substantial compliance with all prior Board remand instructions and has been returned to the Board for further appellate review. As a preliminary matter, the Board acknowledges that the matters of entitlement to SMC, TDIU, and automotive adaptive benefits have previously been remanded as inextricably intertwined with other remanded issues of service connection. See Board remand, May 2021. However, the Board does not find this to be the case at this point in the appeal. Instead, based on the current evidence, regardless of which disabilities may or may not be granted service connection, the Veteran is not shown to have symptoms or impairments from any disability of the severity to convey eligibility for any of the SMC, TDIU, or automotive adaptive benefits on appeal and as such, eligibility for those benefits is determined not to be dependent upon the outcome of the service connection issues again remanded herein. The Board finds that the issues of SMC, TDIU and automotive adaptive benefits are not inextricably intertwined and as such are appropriate for adjudication at this time. SERVICE CONNECTION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 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). Service connection may also be established on a presumptive basis for certain chronic diseases manifested to a compensable degree within a specific period, usually within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. The specifically applicable chronic diseases are listed in 38 C.F.R. § 3.309(a), and include arthritis which will be addressed here. Service connection may also be established on a secondary basis where a claimed disability is proximately due to, or aggravated by another service-connected disease or injury. To establish secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) competent evidence establishing a medical relationship between the service-connected disability and the current disability for which compensation is sought. See Wallin v. West, 11 Vet. App. 509 (1998). The necessary medical relationship may be shown by evidence that the nonservice-connected disability is proximately due to or the result of a service-connected disability, or that the nonservice-connected disease or injury increased in severity beyond its natural progression due to a service-connected disability. 38 C.F.R. § 3.310. The latter circumstance is known by the legal term of "aggravation." 38 C.F.R. § 3.310(b). 1. Service connection for degenerative joint disease of the right shoulder is denied. The Veteran is currently diagnosed with osteoarthritis of the right shoulder, specifically degenerative joint disease (DJD) of the acromioclavicular (AC) joint. See VA treatment records; VA examination, September 2021. Records indicate that this condition was diagnosed in or around 2015, and more than a decade after the Veteran's last period of active service concluded. Id. During active service in April 1987, the Veteran reported back pain lasting two days with a history of pain that leaves after stopping strenuous activities. This pain was described as pain on twisting occurring below the shoulder blades and is considered relevant to this issue only on the basis of proximity to the shoulder blades. However, no disability of the shoulder joint was identified, and the condition was diagnosed as overuse inflammation of the paraspinal muscles. Rest and Motrin were prescribed, and the Veteran was instructed to return to the clinic if the pain did not resolve. Although the Veteran continued to seek medical treatment for other conditions in 1987, he did not report any pain or other problems affecting his right shoulder. Service treatment records. Then, in subsequent Report of Medical History forms completed by the Veteran as part of his Reserve service, he denied ever experiencing swollen or painful joints, arthritis, rheumatism, or bursitis, bone, joint or other deformity, or a painful or "trick" shoulder. See Service treatment records, July 1991 & August 1989. In another Report of Medical History form provided in March 1996, the Veteran then reported a shoulder dislocation had occurred and he now experienced some symptoms of a painful or "trick" shoulder. The Board recognizes that this appears to be the May 1995 shoulder dislocation of the left shoulder for which service connection has already been established. See Rating decision, September 2010. The Veteran does not describe any right shoulder injury occurring during service. As has previously been recognized by the Veteran's accredited representative, after reviewing the claims file in its entirety, the Veteran has with few exceptions "never set forth what his contentions were on the various issues" and the Board is left to infer any potential contentions or relationship to service from the record alone. See Appellant's brief, May 2019. However, as very little is said as to why the Veteran believes his current claimed disabilities are related to his active naval service, the Board has little evidence in this regard upon which to base a decision. The Board may only reach a conclusion based upon what evidence is available as to whether a current claimed disability began during service or is at least as likely as not related to an in-service injury, event, or disease. Here, the Board concludes that, while the Veteran has a diagnosis of right shoulder osteoarthritis, the preponderance of the evidence is against finding that it began during active service, during the one-year presumptive period thereafter, or is otherwise related to an in-service injury, event, or disease. A June 2014 private medical opinion stated that the Veteran "suffered multiple body traumas" during his military service but provided no further detail about the anatomical location of these traumas or any further context for what occurred or how a current condition may be related to that event. The physician then stated, among other opinions, that the Veteran's musculoskeletal disorders generally "are more probable than not secundary [sic] to his military service performance." Medical opinion by Dr. CEMQ, June 2014. However, this opinion is inadequate because it does not offer any medical rationale or reasoning for the conclusion reached. Furthermore, it is not probative because the preponderance of the evidence weighs against finding that a right shoulder injury occurred during active service where the Veteran has not provided any evidence of such an injury or disease. Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). A September 2021 VA examiner then opined that although the Veteran reported pain below the shoulder blades during service in 1987, this is not the same area affected by the currently diagnosed disability of DJD of the AC joint. As such, the Veteran's right shoulder osteoarthritis was opined to be less likely than not (less than a 50 percent probability) incurred in or caused by an in-service injury, event, or disease. This opinion is adequate because it is based on the facts of this case and offers a medical rationale for the opinion reached. While the Veteran may believe that his right shoulder osteoarthritis is related to his naval service, he has not provided specific evidence or argument as to why he believes this to be true. The Board concludes that the preponderance of the evidence weighs against finding that a right shoulder injury occurred during service, or that right shoulder arthritis was identified as a chronic disease during service or manifested to a compensable degree within one year after discharge from active service, or is otherwise related to an in-service injury, event, or disease including the already service-connected left shoulder disability. Service connection for right shoulder osteoarthritis is not warranted. 2. Service connection for a right elbow disability is denied. 3. Service connection for degenerative arthritis of the cervical spine is denied. The circumstances are very similar for the claims of service connection for arthritis of the right elbow and cervical spine, so the Board will address these claims together. As above, the Veteran has described experiencing current right elbow and cervical spine pain but has not described a particular right elbow or cervical spine injury or disease as occurring during his active service. His service treatment records reflect no reports or treatment for a right elbow or cervical spine condition during service. He is currently diagnosed with right elbow lateral epicondylitis and olecranon calcific enthesopathy based upon x-ray examination completed in September 2021. VA examination, September 2021. He is also diagnosed with degenerative arthritis of the cervical spine since approximately 2016. Id. The Veteran reports that his right elbow pain began in 2014-2015, many years after his discharge from active service. Id. As above, the June 2014 private medical opinion diagnosed "chronic cervical spine pain" and osteoarthritis of the elbows without explanation for how this conclusion was reached and osteoarthritis of the right elbow is not seen on later imaging studies. The examiner concluded that the Veteran's musculoskeletal disorders in general were more probable than not related to his naval service, but this opinion is inadequate because it is not supported by the evidence and does not offer any medical rationale for the conclusions reached. The September 2021 VA examiner opined that although there are current diagnoses affecting the right elbow and cervical spine, these conditions are less likely than not incurred in or caused by the Veteran's active naval service because there is no evidence in the service treatment records, or presented by the Veteran, of any right elbow or cervical spine injury or disease during service. The Veteran denied such symptoms and no such disability was identified on medical reports during his subsequent Reserve periods of service. See, e.g., Service treatment records, May 2005, April 2000, March 1996, July 1991, August 1989. The Board concludes that the preponderance of the evidence weighs against finding that a right elbow or cervical spine injury occurred during service, or that cervical spine arthritis was identified as a chronic disease during service or manifested to a compensable degree within one year after discharge from active service. Service connection for right elbow lateral epicondylitis and olecranon calcific enthesopathy and degenerative arthritis of the cervical spine is not warranted, and these claims must be denied. 4. Service connection for degenerative disc disease of the lumbar spine is denied. The circumstances related to the lumbar spine are virtually identical to those discussed previously for the claims above. The Veteran reported back pain during service in April 1987 as occurring beneath the shoulder blades. This appears to have resolved during service because no further treatment or report of low back symptoms is seen. The Veteran routinely denied recurrent back pain or any back injury in Reports of Medical History completed after 1987 during periods of Reserve service in August 1989, July 1991, April 2000, and May 2005. Service treatment records. Lumbar spine degenerative joint disease was diagnosed after service in or around 2016. As for each of the conditions above, the June 2014 medical opinion is inadequate because it is not supported by a medical rationale. The September 2021 VA medical opinion found that the in-service complaint of overuse inflammation was acute and transitory and resolved with treatment during service. The Veteran's current diagnosed lumbar spine condition is found by the examiner to be part of the normal aging process and is less likely than not related to the Veteran's naval service. The Board concludes that the preponderance of the evidence weighs against finding that a lumbar spine injury or disease occurred during service, or that lumbar spine arthritis was identified as a chronic disease during service or manifested to a compensable degree within one year after discharge from active service. Service connection for degenerative arthritis of the lumbar spine is not warranted, and these claims must be denied. 5. Service connection for a bilateral upper extremity neurological disorder is denied. It is uncontested that the Veteran currently has right carpal tunnel syndrome for which he has received prior surgical treatment. VA examination, September 2021. Upon VA examination in September 2021, the Veteran was also identified as having mild left upper extremity numbness although an official diagnosis of left carpal tunnel syndrome was not rendered. The Board determines that based upon the symptoms described, and resolving reasonable doubt in favor of the Veteran, he has a functional impairment of earning capacity due to his left upper extremity numbness, and the condition is considered a disability for the purposes of this decision. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 201) (holding that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity"). The record contains no evidence in the service treatment records or otherwise offered by the Veteran that he experienced an onset of right carpal tunnel syndrome or other upper extremity neurological symptoms during his active service. The September 2021 VA examiner opined that bilateral carpal tunnel syndrome was less likely than not incurred in or caused by the Veteran's naval service because there is no indication of specific physical trauma, contemporaneous records are silent as to any report or indication of the claimed condition, and carpal tunnel syndrome was not diagnosed until many years after active service. The Veteran has made no other assertion as to why he believes a bilateral upper extremity neurological disability is related to his active service. The preponderance of the evidence weighs against the claim, and service connection must be denied. 6. Service connection for a bilateral lower extremity neurological disorder is denied. The Board concludes that the Veteran does not have a current diagnosis of a right or left lower extremity neurological disorder and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Furthermore, the Board does not find symptoms of pain or numbness that reach the level of a functional impairment of earning capacity. Instead, the September 2021 VA examiner evaluated the Veteran and determined that there was no objective evidence of peripheral neuropathy or radiculopathy affecting the lower extremities. All lower extremity nerves were evaluated as normal. Moreover, the Veteran did not describe experiencing symptoms affecting the lower extremities, but instead only described pain and numbness in the hands as addressed in the issue above. The Veteran described no lower extremity symptoms attributable to any peripheral nerve condition in an examination specifically for this purpose. Also, despite regular treatment for multiple service-connected and nonservice-connected medical conditions, VA and private treatment records do not contain a diagnosis of a bilateral lower extremity neurological disorder. Although the June 2014 private medical opinion stated that the Veteran had a diagnosis of "peripheral neuropathy upper/lower limbs." There is no medical basis indicated for this diagnostic finding and the Board finds that this unsupported statement is outweighed by the body of contrary medical evidence that does not find a diagnosed lower extremity neurological disorder to be present. In all, as the Veteran does not describe lower extremity neurological symptoms and the preponderance of the competent and credible medical evidence is also against finding such a disability, the claim of service connection must be denied. 7. Service connection for prostate cancer is denied. This issue was previously remanded by the Board in May 2021 because the issue had been inadvertently dropped from the Supplemental Statement of the Case (SSOC) issued in August 2020 after a prior July 2019 remand. This procedural error was remedied by issuance of the September 2021 SSOC which did include the issue of service connection for prostate cancer. There is no question that the Veteran has been diagnosed with prostate cancer and underwent a prior radical prostatectomy. See, e.g., VA treatment records, July 2021, November 2017, August 2017. However, the Veteran has not described how or why he believes the disability is related to his military service. The service treatment records do not describe any finding of prostate cancer, or any identifiable symptoms of prostate cancer. The record does not otherwise present any indication of a relationship between the current disability and the Veteran's active service. The claim must be denied. Increased Ratings 8. SMC based on the need for the regular aid and attendance of another person or housebound status is denied. Upon examination in January 2020, specifically to address the need for the aid and attendance of another person, the Veteran reported that there were no self-care skills that he was unable to perform. He was completing his own feeding, dressing, undressing, bathing, grooming, toileting, etc. The Veteran expressed no complaints of dizziness, loss of memory, or poor balance that might limit his ability to protect himself from the hazards or dangers of his daily environment. He described his typical day as having breakfast, doing light duties around the house, and running various errands. He hoped to attend additional college education. VA examination, January 2020. The Veteran indicated that he does not need this type of aid and assistance and this benefit was requested by mistake. Id. The Board notes for the sake of clarity that it does not appear that the Veteran explicitly filed a claim seeking SMC due to aid and assistance, but rather that such a claim was inferred from a claim seeking a TDIU rating. See, e.g., Rating decision, March 2016; Supplemental claim, October 2015. The Board also acknowledges argument presented by the Veteran's representative in a May 2019 brief that the Veteran's service-connected left shoulder condition "interferes with his ability to take a bath." However, interference, difficulty, or functional impact alone is inherent in the disability rating assigned and is not necessarily of an equivalent severity as requiring the regular aid and assistance of another person, and the Veteran denies having that level of need. The Veteran's own statements as to the lack of need for assistance have greater evidentiary weight. Regarding housebound status, the Board acknowledges that in a translated March 2015 application form for benefits from the Social Security Administration, the Veteran reported he only leaves home for appointments because he is very sick. He says that he does not go out alone because he gets angry and has panic attacks. On this basis, the Board considered whether a remand may be required to wait for the outcome of the Veteran's claim of service connection for an acquired psychiatric condition, but because other evidence outweighs this assertion and the Board finds that the Veteran is not substantially confined to his dwelling and the immediate premises during the pendency of this claim (regardless of cause), then this claim is not inextricably intertwined with the pending service connection claim and is ready for adjudication at this time. Stated another way, the preponderance of the evidence does not support that the Veteran is restricted to his home or its immediate vicinity, regardless of which disability is alleged to have resulted in the report of being housebound. Evidence that reflects the Veteran is not, in fact, housebound includes VA vocational rehabilitation reports from June and July 2020 that show the Veteran was able to complete a bachelor's degree in business administration in May 2020, was willing to commute for work and/or school up to 75 miles and wished to pursue a graduate degree. Additionally, the January 2020 VA examination for aid and attendance or housebound status explicitly found that the Veteran was not restricted to his home or its immediate vicinity, did not require the assistance of another person in reporting for the examination, ambulated without assistance for up to 3 blocks, and was unrestricted in his ability to leave his home. In a January 2021 VA notation of a telephone consultation, the Veteran described shopping for food for his father, studying for a graduate degree, and helping to distribute lunches and other work to help his community. Although not conclusive, the Board finds this to generally be inconsistent with confinement to one's own home. In all, the Veteran denies the need for the regular aid and assistance of another person, and the preponderance of the evidence outweighs the Veteran's limited assertion that he is housebound. The Board finds that the Veteran is not substantially confined to his home or its premises. SMC is not warranted on either basis, and the appeal is denied. 9. A TDIU rating is denied. A total rating based on individual unemployability may be granted where a veteran is "unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities." 38 C.F.R. § 4.16. If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a). Here, the Veteran has more than one service-connected disability, and a combined rating of 70 percent or greater was in effect for a brief portion of the period on appeal, specifically from December 8, 2014 to February 1, 2015, under the provisions of 38 C.F.R. § 4.30 due to convalescence after a knee surgery. Service connection and the associated disability ratings were in effect for the following disabilities: left shoulder (20 percent), tinnitus (10 percent), right knee meniscal tear (20 percent from June 26, 2014 to December 8, 2014; 100 percent from December 8, 2014 to February 1, 2015; 10 percent from February 1, 2015 to present), COPD (zero percent from June 26, 2014 to January 19, 2020, then 10 percent), hypertension (zero percent), and right knee scar (zero percent). However, even when the minimum percentage thresholds were not met for the majority of the period on appeal because less than a combined 70 percent disability rating has been in place, entitlement to a TDIU rating on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). Rating boards will refer to the Director of the Compensation Service for extraschedular consideration all cases of Veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage requirements set forth in 38 C.F.R. § 4.16(a). However, this is not applicable here because the Veteran is not shown to have been unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities at any time during the present appeal. In determining whether the Veteran is entitled to a TDIU rating, neither his non-service-connected disabilities nor his age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993); 38 C.F.R. § 3.341(a). In determining whether the Veteran can obtain and maintain substantially gainful employment, the United States Court of Appeals for Veterans Claims (Court) in Ray v. Wilkie, 31 Vet. App. 58, 72 (2019) listed some factors the Board may consider to guide its determination. In Ray, the Court held that the phrase "unable to secure and follow a substantially gainful occupation" in § 4.16(b) has both an economic and a noneconomic component. Ray, 31 Vet. App. at 73. The Court further held that "[i]n determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to": (1) The veteran's history, education, skill, and training; (2) Whether the veteran has the physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue, in which factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and (3) Whether the veteran has the mental ability to perform the activities required by the occupation at issue, in which factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity. Additionally, the Court held that, "By discussing [the] potentially relevant factors, we don't create a checklist that must be run completely through in every case. Instead, discussion of any factor is only necessary if the evidence raises it." Id. at 62. For the following reasons, the Board finds that the preponderance of the evidence weighs against the claim that the Veteran is unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities, and as such a total disability rating is not warranted on this basis. In addition to many years of service in the Naval Reserve, the Veteran worked full-time in skilled labor as a splicer for a telephone company for approximately 25 years from 1988 to 2013. Veteran's application for TDIU, February 2015; Social Security application, March 2015. He reports attaining a bachelor's degree during the period of this appeal and continuing to pursue a master's degree in human resources. VA treatment, January 2021. The record shows that the Veteran also has experience in administrative responsibilities from his reserve duties as a yeoman. VA Vocational rehabilitation needs inventory, June 2020. Although there are physical limitations from his currently service-connected disabilities, VA treatment and examination records show that those limitations are not of such a severity as to preclude him from securing and following a substantially gainful occupation. Instead, the Veteran has extensive work history, education, skills, and training, and has successfully completed a college degree during this appeal. It is important to note that the assigned disability ratings in themselves are recognition of the average impairment in earning capacity that results from these disabilities. "Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In other words, the Board does not dispute that the Veteran is significantly impacted by his service-connected disabilities and the functional impairment that they produce in his everyday life, including an occupational setting, as this impairment is the basis for the existing disability ratings and their associated compensation. However, the question here is whether those service-connected disabilities alone render the Veteran unable to secure or follow a substantially gainful occupation, and the evidence weighs against this finding. The appeal must be denied. Automobile & Adaptive Equipment 10. Eligibility for financial assistance in the purchase of one automobile or other conveyance and automobile adaptive equipment, or automobile adaptive equipment only, is denied. As true with some of the issues above, it is not clear that the Veteran explicitly claimed the automotive adaptive benefits addressed here, and he has expressed no specific contentions or arguments as to why he believes that he may be entitled to these benefits. However, the claim was inferred by the agency of original jurisdiction and the appeal has been perfected. It will be adjudicated by the Board as such. Financial assistance in acquiring an automobile (or other conveyance) with adaptive equipment is available only where one of the following exists as the result of injury or disease incurred or aggravated during active service: (1) loss or permanent loss of use of one or both feet; (2) loss or permanent loss of use of one or both hands; (3) permanent impairment of vision of both eyes, meaning central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye; (4) severe burn injury precluding effective operation of an automobile; or (5) amyotrophic lateral sclerosis (ALS). Here, the Veteran does not have a service-connected vison impairment, burn injury, or ALS. Thus, the remaining eligibility criteria for consideration are whether he has loss or permanent loss of use of one or both hands or feet. The applicable regulation does not further define the phrase "loss or permanent loss of use." Under the eligibility criteria found in 38 U.S.C. § 3901 and 38 C.F.R. § 3.808, the appellant must show that he or she had anatomical loss of a foot or hand, or permanently lost the use of a foot or hand due to service-connected disability. The Board notes that the term "loss of use" is used in several places in various statutes and regulations describing disability ratings by VA. In the context of special monthly compensation under 38 C.F.R. § 3.350(a)(2)(i), loss of use of a hand or a foot will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. A less restrictive definition is written into 38 U.S.C. § 2101 and 38 C.F.R. § 3.809 regarding specially adapted housing. That regulation specifies that "loss of use" was defined by the adjacent modifier, "such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair." See Jensen v. Shulkin, 29 Vet. App. 66, 78-79 (2017). However, this modifier is noticeably absent from 38 U.S.C. § 3901 and 38 C.F.R. § 3.808 and had Congress or the Secretary of VA wished for such a definition to apply to the legal requirements for automobile and adaptive equipment benefits, it presumably would have been included. As such, loss of use under 38 C.F.R. § 3.808 will be taken to mean actual loss of functional use of the body part(s), with any need of assistive devices being relevant to, but not dispositive of the question of whether the Veteran experiences a permanent loss of use. It is also possible to establish eligibility for financial assistance for the purchase of automobile adaptive equipment only (i.e., not including the automobile or other conveyance itself), based upon ankylosis of one or both knees or one or both hips. 38 C.F.R. § 3.808. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary 94 (31st ed. 2007). In this case, service connection is in effect for the following disabilities: residuals of a left shoulder dislocation with degenerative joint disease and impingement syndrome, tinnitus, a right knee meniscal tear and associated scar, COPD, a left elbow disability, and hypertension. However, considering the relevant evidence in its entirety, the Board finds that the Veteran's service-connected disabilities do not result in such a severe degree of functional impairment as to approximate "permanent loss of use" of at least one foot or hand, or ankylosis of either knee, nor does the Veteran assert such disability. Instead, the June 2016, January 2020, and September 2021 VA examinations of the knees and lower legs each confirmed no ankylosis of the knee joints. The December 2016, January 2020, and September 2021 VA examinations of the upper extremities indicated no impairment of a severity equating to the loss of use of the hands. The January 2020 VA examination indicated the Veteran arrived by car and did not require an attendant. The Veteran described having the ability to run various errands on his own, although it is unclear as to whether he drove himself. Nonetheless, there was no functional restriction found with reference to strength and coordination in the right upper extremity, and the left shoulder impairment noted only an impact as to reaching or lifting, not use of the hand. The Veteran has not described loss of use of a hand or foot, or symptoms of a severity equivalent to the loss of use of a hand or foot. A preponderance of the evidence is found to demonstrate that while the Veteran suffers from pain and functional impairment from his service-connected left shoulder, left elbow, and right knee disabilities, he retains the ability to walk and make use of his hands and feet, even when assisted by a right knee brace. Therefore, the weight of the evidence is against finding that the Veteran has permanent loss of use of a hand or foot due to service-connected disability, and there is no ankylosis of either knee. In so finding, the Board recognizes that the Veteran suffers impairment due to his service-connected disabilities that could potentially benefit from automobile adaptive equipment in some form. However, eligibility for this benefit is determined by the existing law and regulations that require the Veteran to meet at least one of the six criteria enumerated under 38 C.F.R. § 3.808. The claim cannot be granted based upon need or usefulness alone, without meeting the underlying eligibility criteria. Because the Veteran does not have service-connected disability resulting in the loss or permanent loss of use of one or both hands or feet, ankylosis of his knees or hips, and does not have any of the other physical disabilities listed among the relevant criteria, he does not qualify as eligible for financial assistance in the purchase of an automobile or other conveyance with adaptive equipment, or for adaptive equipment only, under 38 C.F.R. § 3.808. As such, the appeal must be denied. REASONS FOR REMAND 12. Service connection for a left knee disability is remanded. The Veteran initially reported that his left knee injury occurred due to a slip and fall in August 2008 during a "Panamax" training exercise. See VA examination, August 2009. He was diagnosed with a left knee strain at the time. Private hospital record, August 2008 (showing diagnosed left knee sprain in record translated from Spanish). Subsequent VA medical opinions have generally not addressed this injury as it did not occur during a period of active-duty service. See, e.g., VA opinion, September 2021. However, the Board acknowledges that the injury in question may have occurred during a period of active or inactive duty for training. Active duty for training (ACDUTRA) is, among other things, full-time duty in the Armed Forces performed by Reservists or members of the National Guard of any state for training purposes. See 38 U.S.C. § 101(22) (2012); 38 C.F.R. § 3.6(c) (2018). Of a similar nature, inactive duty for training (INACDUTRA), is, in general, part-time duty by Reservists or National Guard members for training purposes, sometimes characterized as "weekend drill." See 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d). Either of these types of service are considered active military service for the purpose of establishing VA benefits when the individual concerned was disabled from an injury incurred or aggravated in the line of duty during such period. Id. Active service also includes authorized travel to or from such duty or service. 38 U.S.C. § 106(d); 38 C.F.R. § 3.6(e). Here, the record does not establish the Veteran's duty status at the time of the August 2008 injury, nor has a VA examiner adequately addressed whether any of the currently diagnosed left knee disabilities is related to that event. A remand is necessary. 13. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Board cannot make a fully-informed decision on the issue of service connection for an acquired psychiatric disorder because no VA examiner has adequately opined whether the Veteran's diagnosed depressive disorder with alcohol use disorder has been aggravated (increased in severity) due to the physical symptoms from his service-connected disabilities. The matters are REMANDED for the following action: 1. Attempt to verify the Veteran's duty status for the period of training including the Panamax exercise and documented knee sprain occurring on or around August 22, 2008. If this injury occurred during a period of active duty for training or inactive duty for training, that fact should be documented in the claims file along with the information used to reach that determination. (Continued on the next page) 2. If the August 2008 knee injury occurred during a period of active duty for training or inactive duty for training, obtain an addendum opinion as to whether it is at least as likely as not that the current left knee degenerative arthritis, patellofemoral pain syndrome, or meniscal syndrome post-arthroscopy, or any other current left knee disability is related to service, including the August 2008 fall with resulting knee sprain. A medical rationale must be provided to support the opinion offered. 3. Obtain an addendum opinion regarding whether the Veteran's depressive disorder with alcohol use disorder is at least as likely as not (a) proximately due to or (b) aggravated beyond its natural progression by the Veteran's physical symptoms due to his service-connected disabilities. The Board leaves it to the professional judgment of the examiner as to whether the Veteran needs to be re-examined to form an informed opinion in this regard. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. McDonald, 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.