Citation Nr: 21075589 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 15-06 594A DATE: December 20, 2021 ORDER Entitlement to a rating for lumbar strain in excess of 20 percent prior to June 2, 2010 is denied. Entitlement a rating for right ankle sprain in excess of 10 percent prior to June 2, 2010 and in excess of 20 percent thereafter is denied. Entitlement to an initial rating in excess of 10 percent for right knee degenerative joint disease (DJD) is denied. Entitlement to service connection for a neck disability is denied. Entitlement to special monthly compensation (SMC) at the housebound rate is denied. REMANDED Entitlement to SMC based on a need for aid and attendance is remanded. FINDINGS OF FACT 1. Prior to June 2, 2010, the Veteran's lumbar strain caused limitation of forward flexion to no less than 60 degrees with pain beginning at 50 degrees. 2. Prior to June 2, 2010, the Veteran's right ankle sprain caused impairment most closely approximating moderate limited motion, including limitation of dorsiflexion to no less than 20 degrees and plantar flexion to no less than 15 degrees. 3. As of June 2, 2010, the Veteran has the maximum 20 percent schedular rating for right ankle sprain. 4. The Veteran's right knee disability has manifest with limitation of flexion to no less than 110 degrees with pain beginning at 80 degrees. 5. The Veteran's current cervical spine disability did not onset in service and is not causally related to service, nor was it caused or aggravated by any service-connected disability, including his headache and lumbar spine disability. 6. The Veteran does not have a single service-connected disability rated as total and additional service-connected disability or disabilities independently ratable at 60 percent or more nor is he permanently housebound. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for lumbar strain prior to June 2, 2010 have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5237. 2. The criteria for an evaluation in excess of 10 percent prior to June 2, 2010 and in excess of 20 percent thereafter for right ankle sprain have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5271. 3. The criteria for an evaluation in excess of 10 percent right knee DJD have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5260. 4. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309. 5. The criteria for SMC at the housebound rate have not been met. 38 U.S.C. §§ 1114(s), 5107; 38 C.F.R. §§ 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Air Force from September 1970 to September 1973 and from June 1977 to May 1978, and on active duty in the Army from September 1986 to October 1990. In August 2018, the Veteran and his spouse testified at a Board hearing before the undersigned, and a transcript of that hearing is of record. The Board remanded the issues in March 2020 and January 2021 for further development. They have now returned to the Board. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). See AB v. Brown, 6 Vet. App. 35 (1993). 1. Entitlement to an initial rating in excess of 20 percent for lumbar strain prior to June 2, 2010 The Veteran contends he is entitled to a higher initial rating for his service-connected lumbar strain. He currently has a 20 percent rating for his lumbar strain under Diagnostic Code 5237 from October 13, 2009 to June 2, 2010. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. 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 be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[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."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). A September 2009 VA treatment record notes the Veteran to have normal flexion and extension of his back. In February 2010, the Veteran underwent an examination in connection with his Social Security Administration (SSA) disability claim. The examiner stated that examination showed tenderness over the lumbar spine but normal range of motion. The Veteran underwent a VA examination in March 2010. The examination report indicates that the Veteran does not have muscle spasm, localized tenderness, or guarding severe enough to be responsible for abnormal gait or abnormal spina contour. On range of motion testing, the Veteran had forward flexion to 60 degrees with pain starting at 50 degrees, and extension and right and left lateral flexion to 20 degrees with pain beginning at 15 degrees and right and left lateral rotation to 20 degrees with pain beginning at 10 degrees. He had pain following repetitive emotion but no additional limitations after three repetitions. On VA examination in March 2011 the Veteran reported that since his previous VA examination his back had worsened, with more locking and pain. Repetitive motion testing showed the Veteran's flexion to be limited to 30 degrees. In May 2021 a VA opinion was obtained as to whether back range of motion measurements for active motion, passive motion, weight-bearing, and non-weight-bearing can be estimated for the period from October 13, 2009, to June 1, 2010. The VA reviewer opined that such an estimate, more than a decade later, would be mere speculation. The Board finds that a preponderance of the evidence is against finding that the Veteran's back disability met the criteria for a rating in excess of 20 percent from October 13, 2009 to June 2, 2010. The March 2011 VA examination is the earliest evidence reflecting that the Veteran's back disability more closely approximated the criteria for a higher, 40 percent rating, specifically, forward flexion of the thoracolumbar spine to 30 degrees or less. The Board notes that the Veteran reported at that examination that his back disability had worsened since his prior examination in March 2010. At that examination, testing showed the Veteran to have forward flexion to 60 degrees with pain starting at 50 degrees and no additional limitations after three repetitions. There is no range of motion testing or lay evidence from the period from October 13, 2009 to June 2, 2010 suggesting that the Veteran's forward flexion was limited to 30 degrees or less. The Board acknowledges the Veteran's report of low back pain, stiffness, weakness, and spasms. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the evidence does not support that the Veteran's condition more closely met the criteria for a 40 percent rating. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Thus, based on the forgoing, the Board finds that a preponderance of the evidence is against a rating in excess of 20 percent from October 13, 2009 to June 2, 2010, the benefit of the doubt doctrine does not apply, and the claim must be denied. 2. Entitlement to a rating for right ankle sprain in excess of 10 percent prior to June 2, 2010 and in excess of 20 percent thereafter The Veteran contends he is entitled to a rating greater than 10 percent prior to June 2, 2010 and a rating greater than 20 percent as of June 2, 2010 for his right ankle sprain. His current rating is assigned under Diagnostic Code 5284-5271. Diagnostic Code 5271 applies to limitation of motion of the ankle. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limited motion of the ankle and a 20 percent rating is warranted for marked limited motion of the ankle. 38 C.F.R. § 4.71a. According to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension." See www.merriam-webster.com/dictionary/moderate. "Marked" means "having a distinctive or emphasized character." See www.merriam-webster.com/dictionary/marked. Effective February 7, 2021, VA amended the rating criteria for Diagnostic Code 5271. 85 Fed. Reg. 76,453 (Nov. 30, 2020). Under the new criteria, a 10 percent rating is warranted for moderate limited motion of the ankle (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion.) A 20 percent rating is warranted for marked limited motion of the ankle (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion.) As this regulatory change was enacted during the pendency of this appeal, the Board will consider both the old and new versions of the rating criteria from the effective date and apply the version most favorable to the Veteran. In February 2010 the Veteran underwent an examination in connection with his SSA disability claim. He was noted to have grossly normal range of motion in his right ankle. The Veteran underwent a VA examination in March 2010. The Veteran reported constant throbbing pain and edema in the right ankle and intermittent cramping. The Veteran reported symptoms of giving way, instability, pain, stiffness, weakness, and locking one to three times a month. Examination showed edema, tenderness, and guarding of movement but no instability. Range of motion testing showed dorsiflexion to 20 degrees and plantar flexion to 15 degrees. Pain was noted with motion but no additional limitations after three repetitions. The Veteran underwent another VA examination in March 2011. He reported less movement; more popping, pain, swelling, and limited mobility; and weakness leading his ankle to twist more easily causing him to fall. He reported wearing a brace. On examination, the Veteran was found to have ankle instability without enough strength to resist movement well with inversion/eversion. Range of motion testing showed dorsiflexion and plantar flexion both to 10 degrees with pain at the end range. There was no additional limitation after three repetitions. On VA examination in December 2014, the Veteran reported swelling and sharp pain. He reported flare-ups twice a month for an hour and a half to two hours that reduces his function by an additional 30 percent. He stated that during a flare-up he cannot walk or put on his shoe. Range of motion testing showed dorsiflexion to 15 degrees and plantar flexion to 40 degrees, both with pain. No additional loss of function was found after three repetitions. On VA examination in October 2020, range of motion testing showed dorsiflexion to 15 degrees and plantar flexion to 40 degrees with pain and no additional loss after three repetitions. The examiner indicated there would be no additional loss of functional ability with repeated use over time. In a May 2021 VA opinion, a VA reviewer opined that it would be mere speculation to offer a current opinion as to range of motion with active, passive, weight-bearing, and nonweight-bearing motion between October 2009 and June 2010, but noted that the Veteran worked as a commercial truck driver without restrictions during that time. In June 2021 the Veteran underwent another VA examination. He reported chronic, constant aching pain in the right ankle and stated that during a flare-up he is unable to walk and stand for a long time. Range of motion testing showed plantar flexion to 35 degrees and dorsiflexion to 20 degrees with both passive and active motion. There was no additional loss of function after three repetitions. With repeated use over time and during a flare-up, the examiner estimated plantar flexion would be limited to 30 degrees and dorsiflexion to 15 degrees. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for right ankle strain prior to June 2, 2010. Range of motion testing on VA examination in March 2010 showed dorsiflexion to 20 degrees and plantar flexion to 15 degrees while a private February 2010 VA examination indicated grossly normal range of motion. The Board acknowledges the Veteran's lay reports of symptoms and that he has had functional loss due to pain, weakened movement, stiffness and locking, and instability. However, even considering the Veteran's lay reports of symptoms and functional loss, the Board finds that the degree of additional limitation would not result in symptoms more nearly approximating marked limited motion. The Board has considered whether any other Diagnostic Codes related to disabilities of the ankle would provide for a higher disability rating prior to June 2, 2010. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. With respect to the period beginning June 2, 2010, the Veteran is in receipt of the highest schedular rating for limited motion of the ankle, therefore, there is no basis to award a higher rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the ankle would provide for a higher disability rating as of June 2, 2010. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. As the Veteran already has the maximum schedular disability rating as of June 2, 2010, the appeal is denied. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 10 percent prior to June 2, 2010 and a rating in excess of 20 percent as of June 2, 210 for right ankle sprain. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to an initial rating in excess of 10 percent for right knee degenerative joint disease (DJD) The Veteran contends he is entitled to a higher initial rating for his right knee degenerative joint disease. He currently has a 10 percent initial rating under Diagnostic Code 5003-5260. Diagnostic Code 5260 applies to limitation of flexion of the leg. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Codes 5260 and 5261 were not affected by the February 2021 regulatory changes. The Veteran was afforded a VA examination in March 2010. Range of motion testing showed flexion to 120 degrees and normal extension. There was no additional limitation after three repetitions. On VA examination in March 2011, range of motion testing showed flexion to 110 degrees with pain beginning at 80 degrees and normal extension. The Veteran underwent another VA knee examination in December 2014. Range of motion testing showed flexion to 120 degrees and extension to 0 degrees with pain on flexion and with weight bearing. There was no additional loss after three repetitions. The examiner stated that it would be mere speculation to opine as to range of motion during a flare-up or with repeated use over time. The Veteran reported swelling and disturbance of ambulation with increased pain with sitting and standing. The Veteran stated that he has flare-ups twice a week lasting four to five hours that are precipitated by prolonged standing, pivoting, and walking and stated that he has an additional 70 percent restriction of activity during a flare-up. Range of motion testing done on VA examination in September 2020 showed flexion to 130 degrees and extension to 0 degrees with pain on both motions and with weight bearing. There was no additional loss of range of motion after three repetitions. The examiner opined that there would not be an additional loss of functional ability with repeated use over time. The examiner indicated that the Veteran denied having flare-ups. In a May 2021 addendum opinion, a VA examiner stated that active and passive range of motion in weight bearing and nonweight bearing would be the same but that it would be mere speculation to opine on range of motion prior to September 2020. In June 2021 the Veteran was afforded another VA knee examination. He reported flare-ups of his right knee condition with prolonged sitting, standing, and walking lasting 30 minutes every day. Range of motion testing showed flexion to 120 degrees with pain and extension to 0 degrees. Active and passive range of motion were the same. There was no additional loss after three repetitions. The examiner estimated a reduction in flexion to 115 degrees with repeated use over time and during a flare-up, noting increased pain with repeated range of motion. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for right knee DJD. Range of motion testing on multiple VA examinations showed flexion to no less than 110 degrees, with pain beginning at 80 degrees. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, particularly during flare-ups and after repetitive use. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the Board finds that the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). As outlined above, extension was consistently found to 0 and as such a separate rating under Diagnostic Code 5261 is not warranted. The Board notes that in a June 2021 rating decision, service connection for right knee subluxation or instability was granted with a 20 percent rating effective June 16, 2021. That rating is not on appeal. The Board does not find any other disability rating is applicable that would provide the Veteran with a higher or separate rating. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent right knee DJD. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Service Connection 1. Entitlement to service connection for a neck disability The Veteran contends he has a neck disability related to his service, to include his service-connected headache disability. Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Additionally, service connection may be granted, on a secondary basis, for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the non-service-connected disease, will be service-connected. Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the non-service-connected disease or injury is said to have been aggravated by the service-connected disease or injury. 38 C.F.R. § 3.310. To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Service connection may also be granted on a presumptive basis for certain chronic diseases, including arthritis, if shown to be manifest to a degree of 10 percent or more within one year following a veteran's separation from active service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309 The Veteran's service treatment records reflect a complaint of neck pain in March 1978 exacerbated by playing volleyball. The Veteran was assessed with muscle strain with some nerve root compression. The Veteran's May 1978 separation examination notes a normal spine as does his August 1986 National Guard enlistment examination. In July 1978 the Veteran underwent a VA compensation and pension examination in connection with an original claim for benefits, including muscle spasm from muscle strain with some nerve root compromise in March 1978. The examination, as well as a September 1978 examination, reflected normal range of motion of the cervical spine. A September 2012 VA treatment record notes the Veteran's complaint of neck pain starting 12 years ago that sometimes causes a headache. A December 2017 MRI showed spondylosis of the cervical spine. The Veteran was afforded a VA examination in June 2021. The examiner noted the Veteran's diagnoses of cervical strain in 1978 and degenerative arthritis in 2017. The examiner opined that the Veteran's current neck disability is less likely than not related to service. The examiner stated that the Veteran's in-service neck strain was due to an acute injury and is not the cause of his current degenerative joint disease of the cervical spine. The examiner stated that there is no evidence of chronicity of care and symptoms are subjective only. The examiner further opined that the Veteran's service-connected lumbar strain is less likely than not related to his cervical disability. The examiner explained that lumbar strain does not caused or impact cervical muscles or vertebrae and therefore does not result in cervical strain or cervical degenerative joint disease. The examiner concluded that cervical strain and cervical degenerative joint disease are separate entities from lumbar strain and unrelated to it. A VA opinion was obtained in May 2021 as to whether there is a relationship between the Veteran's service-connected headache disability and his cervical spine disability. The examiner opined that it is less likely than not that the Veteran's neck strain is due to his migraine headaches as there is no pathophysiological nexus to connect the two and that the Veteran's migraines did not increase the severity of his neck pain for the same reason. The acknowledges the Veteran's own opinion that there is a relationship between his current neck disability and his service and/or his service-connected headache disability. However, the Board finds that as a lay person the Veteran does not have the education, training, or experience to competently opine as to the etiology of his current cervical spine disability, which is a complicated medical question. The Board finds the June 2021 VA examiner has offered the most probative opinion as to direct service connection. The examiner considered the Veteran's in-service neck injury but opined that it is less likely than not related to the Veteran's current neck condition. The Board further finds that a preponderance of the evidence is against service connection on a secondary or aggravation basis. Specifically, June 2021 VA examiner opined that the Veteran's current cervical spine disability is less likely than not related to the Veteran's service-connected lumbar spine disability and the May 2021 VA reviewer opined that the Veteran's current cervical spine disability is less likely than not related to the Veteran's service-connected headache disability, to include both on the basis of causation and aggravation. Finally, the Board finds that a preponderance of the evidence is against finding that the Veteran's cervical spine arthritis onset in service or within a year of his separation from service. Based on the forgoing, a preponderance of the evidence is against service connection, the benefit of the doubt doctrine does not apply, and the claim must be denied. Special Monthly Compensation 1. Entitlement to SMC at the housebound rate The Veteran has appealed the issue of entitlement to special monthly compensation. SMC may be awarded at the housebound rate if a veteran has a single service-connected disability rated as total and (1) has additional service-connected disability or disabilities independently ratable at 60 percent or more, or (2) by reason of service-connected disability or disabilities, is permanently housebound. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). A veteran will be determined to be permanently housebound when he is substantially confined to his house (or ward or clinical areas, if institutionalized) or immediate premises due to disability or disabilities when it is reasonably certain that such a condition will remain throughout his lifetime. Id. The Veteran is currently in receipt of SMC at the housebound rate from September 24, 2010 to December 1, 2010. During that period he had a temporary total rating for status post right foot recurrent soft tissue mass excision with residuals under 38 C.F.R. § 4.30. The record does not reflect a 100 percent rating for any single disability for any other time period. However, the Veteran is in receipt of a total disability rating based on individual unemployability (TDIU) from June 2, 2010. An award of a TDIU predicated on a single disability may form the basis for an award of SMC. See Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008). Here, the Board finds that the Veteran's award of TDIU may not be predicated on a single disability. The Veteran's service-connected disabilities consist of adjustment disorder with depressed mood; lumbar strain; asthmatic bronchitis; migraine headaches; right ankle sprain; right foot residuals; right knee degenerative joint disease and instability; left toe disability; left knee degenerative joint disease; tinnitus; fractured rib, right lateral area; bilateral sensorineural hearing loss; excision of lipoma on abdominal wall; residuals of lacerated right index finger; pityriasis rosea; residuals of left retinal vein occlusion; allergic rhinitis; diabetes mellitus; and right and left sciatic nerve impairment. The evidence reflects that the Veteran's work experience is as a truck driver. On his August 2010 application for TDIU the Veteran identified his back disability, ankle disability, and knee disability as preventing him from security or following substantially gainful work. In February 2010, the Veteran was found to be entitled to SSA disability benefits effective from November 2009, with impairments of chronic right knee and leg pain and anxiety-related disorder. In January 2013, a VA vocational rehabilitation counselor determined that it was not feasible for the Veteran to benefit from a program designed to return him to gainful employment. A counseling narrative indicated that his service-connected lumbar strain, bronchial asthma, migraine headaches, right ankle and foot, and knees resulted in a serious employment handicap due to the number of disabling conditions, severity of the disabling conditions, pattern of reliance on government support programs, chronic pain, and lack of education/training for suitable employment. In a September 2016 letter, a private physician assistant indicated opined that the Veteran was unable to engage in any substantial gainful activity by reason of his many chronic debilitating conditions that are expected to last a lifetime. The Veteran testified in the August 2018 Board hearing that he could not work due to his diabetes, knees, foot, and general joint pain. He reported it was hard to climb up and down off the truck and stated that using a computer for more than 10 minutes gives him a migraine. The Board has considered each of the Veteran's service-connected disabilities but finds that none alone supports entitlement to TDIU. Thus, the Veteran does not have a single disability rated as totally disabling and additional service-connected disability or disabilities independently ratable at 60 percent or more. Further, the Veteran has not contended, nor does the evidence support, that he is housebound as a result of his service-connected disabilities. Based on the forgoing, the Board finds that the Veteran does not meet the criteria for SMC at the housebound rate. REASONS FOR REMAND 1. Entitlement to SMC based on a need for aid and attendance Under 38 U.S.C. § 1114(l), SMC is payable if, as the result of service-connected disability, the Veteran is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). Under 38 C.F.R. § 3.352(a), the following factors will be accorded consideration in determining whether the Veteran is in need of regular aid and attendance of another person: the inability of the Veteran to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; inability of the Veteran to feed himself because of the loss of coordination of upper extremities or because of extreme weakness; and the inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers incident to his daily environment. 38 C.F.R. § 3.352(a). At the Veteran's August 2018 Board hearing his wife testified that she assists the Veteran in the bathroom and with getting dressed, suggesting her assistance is needed to protect the Veteran from falls. The Board notes that the Veteran is service connected for a number of musculoskeletal disabilities, including lumbar strain, right ankle sprain, status post right foot recurrent soft tissue mass excision, right knee subluxation or instability, right knee degenerative joint disease, and left knee degenerative joint disease, as well as right and left sciatic nerve impairment. The Board finds that the Veteran should be afforded an aid and attendance examination to obtain an opinion as to whether he requires the assistance of another due to his service-connected disabilities. The matters are REMANDED for the following action: Arrange for the Veteran to undergo a VA aid and attendance examination. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Christensen 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.