Citation Nr: 21077328 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 17-39 930 DATE: December 29, 2021 ORDER Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The record evidence shows that the Veteran's low back disability and left knee disability are not related to active service. 2. The Veteran's service-connected disabilities do not preclude him from securing or maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.400, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1988 to September 1994. These matters are before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Board remanded the claims for further development. There has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for a low back disability is denied. The Veteran contends that he has a low back disability that is related to his military service. VA examination reports dated in November 2016 and October 2019 reflect current diagnosis of degenerative arthritis of the spine. Arthritis is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. The Board finds that the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. The Veteran's low back disability did not onset in service and is not otherwise related to service. The Veteran's service treatment records show that, in February 1989, he reported pain in his coccyx area after falling the day before. The x-rays did not show a fracture, and he was diagnosed with coccyx contusion. A follow-up record three days later noted an assessment of coccyx bruise. There were no further treatments. In the July 1994 separation report of medical history, he denied any recurrent back pain. The corresponding separation exam noted normal evaluation of the spine. The Board notes that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran's post-service private records indicate work-related injuries to his back in 2003 and in 2012. A February 2012 VA record noted the Veteran sought to establish care with VA. His past medical history included "lower back pain: working for a tree company." It also noted the Veteran was seen in 2003 at Sharp Rees for herniated disc. Upon physical examination, he endorsed pain in left lateral paraspinal area around L1. The clinician noted that the back pain was likely a paraspinal strain. He was recommended to continue naproxen and to undergo physical therapy. An October 2012 occupational injury report from Sharp Rees noted the Veteran was employed as a cashier at AM/PM and presented with persistent back pain after sustaining a slip-and-fall in October 2012. He stated he slipped on a newly mopped floor while holding a tray of food. He has been taking old prescriptions of Vicodin and Naproxen for pain. He reported persistent pain to the left side of his midback. He stated he has not missed any time off work. He denied any previous serious back injury. A December 2012 record from Sharp Rees noted the Veteran is a former cashier at AM/PM and lost his job 3 weeks earlier. He reported he was awaiting approval for additional therapy. In a February 2013 private evaluation by Dr. S.L., the Veteran stated that he slipped and fell on a wet floor on October 2, 2012 while working at AM/PM. He stated he was on light duty until November 25, 2012 when he was fired due to a reason unrelated to the accident. The diagnoses included a history of contusion and low back strain. Dr. S.L. commented that, within reasonable medical certainty, the Veteran sustained injuries to the low back as a result of the incident occurring in the course of his employment on October 2, 2012. The records show the Veteran received physical therapy from Dr. S.L. until July 2014. A November 2013 VA record noted history of chronic low back pain secondary to work-related injury while working for a tree company. A March 2014 private evaluation by Dr. P.H. noted the Veteran suffered an injury in October 2012 while working as a cashier/stocker at an AM/PM store. The diagnoses included lumbar sprain/strain and industrial aggravation of lumbar degenerative disc disease with L3 severe foraminal stenosis. Dr. P.H. noted that the cause of the Veteran's disability is directly related to the industrial injury he sustained in October 2012. In an October 2014 private evaluation, Dr. P.H. noted that the Veteran injured his back while working as a housekeeper at Sharp Crossmont Hospital/Sodexho, Inc. in 2002. Dr. P.H. noted that, according to a June 2003 medical note from Dr. J.C., the Veteran injured his back in August 2002 when he went to pull a linen cart into an elevator, when the elevator door began to close and hit him in the back, knocking him forward. Dr. J.C. diagnosed contusion with musculoligamentous strain/sprain of the lumbar spine and degenerative disc disease L2-3 with left-sided disc bulge L2-3. Dr. J.C. noted that the causation was an injury arising out of and occurring in the course of his employment. An October 2014 VA record noted a two-year history of low back pain radiating to the left lower extremity with paresthesias and weakness. In November 2016, the Veteran underwent a VA examination for his back condition. The Veteran was diagnosed with degenerative arthritis of the spine and radiculopathy of the lower extremities. He reported that, in 1989, he was skiing and fell onto his tailbone. He stated he had conservative treatment with some improvement in symptoms. He reported that, in 2003, he hurt his back while working at Grossmont Hospital pushing a gurney and was hit by an elevator door. The examiner opined that the Veteran's back condition is less likely as not incurred in or caused by low back pain that occurred while on active duty. He explained that while a service treatment record from February 1989 noted complaints for pain in the coccyx area after a fall, the separation exam in 1994 noted negative complaints or findings for a back condition. The examiner added that records from 2014 indicate treatment for low back pain 20 years after military service. He noted that, although the Veteran was found to have degenerative arthritis of the spine and radiculopathy of the bilateral lower extremities, considering medical documentation and today's objective findings, there was insufficient evidence to suggest chronic ongoing complaints/treatment for a back condition that incurred in or caused by the low back pain in service. He concluded that a nexus is not established. The Veteran underwent a VA examination in October 2019. He was diagnosed with degenerative arthritis of the spine. He reported that his back condition started in service when he fell down on his coccyx skiing. He stated he had another fall in Okinawa while walking with heavy packs and stumbled. He also stated that he has had ongoing pain since then. He reported a work-related injury around 2002 or 2003 when he was transporting a patient where the elevator door hit him and he fell down. He also reported that he slipped and fell while working at a gas station in 2012. The examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that review of the Veteran's service treatment records reveals that he was evaluated for pain in the coccyx area after falling on February 10, 1989, and an x-ray of the coccyx was normal without any fracture. A follow-up three days later noted coccyx bruise and there were no other lower back or coccyx evaluations thereafter or prior to that fall. The examiner stated that the Veteran denied recurrent back pain in the separation report of medical history, and that his separation physical documented a normal back exam. The examiner further noted that review of his available post-service records reveals a work-related back injury on August 17, 2002. It was documented that he went to pull a linen cart into an elevator when the elevator door began to close and hit him in the back, knocking him forward. He was diagnosed with a contusion with musculoligamentous strain/sprain lumbar spine and degenerative disc disease L2-L3 with left sided disc bulge L2-L3. There was another work-related injury on October 2, 2012. It was documented that he had slipped and fell on a newly mopped floor, twisted his back, and fell on his buttock. He was diagnosed with a thoracic strain initially, then an MRI of the lumbar spine revealed disc herniations at L2-L3 and L3-L4. The October 2019 examiner stated that, collectively, there is no evidence of a chronic lower back condition or pathology in the military service. The Veteran's remote acute coccyx bruise in 1989 had resolved without any documented residuals; his back exam was normal at retirement; and there are no intervening medical records available for review after 1994 that would support any chronic impairment stemming from the service. This examiner stated there is no objective evidence to support any temporal relationship of the coccyx bruise in 1989 which had resolved to the work related injuries in 2002 or 2012 and the acute coccyx bruise in 1989 that resolved did not influence or contribute to the work related injuries/falls in 2002 or 2012. The examiner added that the Veteran's current functional impairment appears to be primarily due to his work-related injury in 2012. He noted there was no evidence that his military service influenced or contributed to the Veteran's current back impairment. The examiner concluded that the Veteran's degenerative arthritis of the spine is less likely than not incurred in or caused by the military service or by the coccyx bruise in 1989 which had resolved. The Board finds the preponderance of the evidence is against granting the Veteran's claim of service connection for a low back disability. The Board notes initially that, to the extent that arthritis is an enumerated condition under 38 C.F.R. § 3.309(a), the evidence of record weighs against finding that arthritis was shown as chronic in service, manifested to a compensable degree within a presumptive period, or was noted in service with attributable continuity of symptomatology. Although the Veteran's service treatment records note a coccyx contusion in 1989, his service treatment records, including the separation evaluation, do not reveal a diagnosis of arthritis. Further, there is no competent evidence of a diagnosis of arthritis within a year of service discharge. While the Veteran is competent to report having experienced symptoms of back pain since service, he is not competent to determine whether arthritis was present and manifested to a compensable degree either in service, or within the presumptive period following discharge. He has not demonstrated the necessary medical expertise (e.g. medical training or credentials) to do so. The issue is medically complex as it requires knowledge of interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007); Kahana v. Shinseki, 24. Vet. App. 428 (2011). Moreover, the lay reports of continuity of low back symptoms since service simply are not credible as his VA and private records do not reveal any complaints or treatment for a back condition until many years after separation. The Board notes that evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Thus, the Board finds that service connection for arthritis of the low back as a chronic disease is not warranted. There also is no competent evidence of record indicating that the Veteran's low back condition otherwise is related to service. The Board finds that the November 2016 and October 2019 medical opinions are probative on this issue as they were based on the examiner's consideration of the entirety of the Veteran's medical history and supported with cogent rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The November 2016 examiner explained that, based on normal spine at separation and treatments for his back many years after service, there was insufficient evidence to suggest chronic ongoing complaints for a back condition that incurred in or caused by the 1989 coccyx pain in service. The October 2019 examiner explained that the Veteran's remote acute coccyx bruise in 1989 had resolved without any documented residuals and that his back exam was normal at separation. He added that the current condition appears to be primarily due to his work-related injury in 2012. The opinions were provided by physicians who possessed the necessary education, training, and expertise to provide the requested opinion. Consequently, the Board gives more probative weight to the competent medical evidence than to the Veteran's contrary lay assertions. He otherwise has not identified or submitted any evidence demonstrating his entitlement to service connection for a low back disability. In summary, the Board finds that service connection for a low back disability is not warranted. 2. Entitlement to service connection for a left knee disability is denied. The Veteran contends that he has a left knee disability that is related to his military service. The Board notes initially that the Veteran's service treatment records show that, in March 1990, he reported left knee pain described as a cramp while running. He was assessed with quadriceps muscle strain. On his July 1994 separation medical history, he reported that his knees were painful and swollen in cold weather. The corresponding separation exam noted normal clinical evaluation of the lower extremities. The Board again notes that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303. The post-service evidence shows that, in a February 2012 VA record, a medical history was noted of left knee medial collateral ligament (MCL) tear in 2009 that appeared to be managed at Sharp Rees. In a March 2014 private evaluation, Dr. P.H. noted that, according to a January 2014 deposition, the Veteran injured his left knee in 2008 or 2009 while working at Western Tree Services. He had an MCL tear, and that he received therapy, shots, and a settlement. Dr. P.H. next noted that, according to a June 2010 treatment record from Dr. S.A., the Veteran injured his left knee after jumping over a fence in a course of employment as a tree trimmer. Dr. S.A. noted a diagnosis a left knee strain with partial MCL tear which was "work related." During a November 2016 VA examination, the Veteran was diagnosed with left knee strain. He did a lot of high impact activities in service and walked for long periods of time which caused pain on both knees. He fell down numerous times carrying heavy backpacks which caused the pain on his knees to become more severe. He developed recurrent pain in his knees since that time. He also reported that he fell while cutting trees during his employment with a tree company in 2008 and that developed a left knee injury at the time. The examiner opined that the Veteran's left knee condition is less likely as not incurred in or caused by swollen painful joints that occurred while on active duty. The examiner explained that the service treatment record regarding the left knee was for a left quadriceps muscle strain which is considered to be pathologically independent from a left knee joint condition. The examiner also explained that, while the 1994 separation evaluation noted swollen painful knee joints, considering the evidence, there was insufficient documentation to suggest a chronic, ongoing complaints or treatment for a left knee condition that began in service. The Veteran underwent a VA examination for left knee in October 2019. He was diagnosed with left knee strain. He fell frequently on his knees during service. He experienced a fall from a tree when trimming a tree during work for a tree company in 2008 and hurt his left knee. He developed left knee pain starting in 2012 when he had an epidural cortisone injection to his back. The examiner opined that the condition claimed was less likely than not incurred in or caused by his service. This examiner explained that review of the service treatment records reveals that the Veteran was seen for left knee pain since "this AM" on March 29, 1990, and the assessment was "quadriceps muscle strain." He noted there are no other left knee evaluations in the service treatment records and that strain was likely acute and did not evolve into a chronic condition. This examiner commented that, while the separation medical history documented "knees swollen and painful in cold weather," subsequent physical exam of the Veteran's lower extremities was documented as normal. The examiner noted that a chronic left knee condition was not established or objectively demonstrated in service. He explained that review of the post-service medical records, in particular medical notes from 2014 which summarize the Veteran's work-related injuries post-service, detail a specific work-related left knee injury in January 2010. It was documented that the Veteran climbed a fence in order to get some branches, the fence was not stable and gave way, causing him to fall. The examiner noted that the Veteran was diagnosed with a MCL sprain and his notes detail chronic left knee pain since that injury. This examiner commented that a pre-existing chronic left knee condition was not objectively demonstrated or documented prior to the left knee injury in 2010, indicating that the Veteran's current left knee condition was less likely to have been influenced by his military service from 1988 to 1994. This examiner added that the acute left quadriceps muscle strain in 1990 had resolved and is unrelated to the current left knee condition and did not influence or contribute to the fall from atop a fence in 2010. The examiner concluded that the Veteran's left knee strain is less likely than not incurred in or caused by the military service or by the painful knees or swollen joints during service and the current knee strain is likely from the work-injury in 2010. The Board concludes that, while the Veteran has a current diagnosis of left knee strain, the preponderance of the evidence weighs against finding that it began during service or is otherwise related to an in-service injury, event, or disease. There was an isolated assessment of quadriceps muscle strain while the Veteran was on active service in March 1990 and his separation exam noted normal clinical evaluation of his lower extremities. His post-service VA and private treatment records do not indicate any complaints of a left knee condition until around 2008, at which time he had a work-related injury. The Board again notes that evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. See Maxson, 230 F.3d at 1333. Critically, the November 2016 and October 2019 VA examiners opined that his left knee condition was less likely than not related to his active service. The November 2016 examiner explained that the left quadriceps muscle strain in March 1990 is considered to be pathologically independent from a left knee joint condition and there was insufficient documentation to suggest a chronic, ongoing complaints or treatment for a left knee condition that began in service. The October 2019 examiner explained that the acute left quadriceps muscle strain in 1990 had resolved and did not evolve into a chronic condition. He added that the current knee strain is likely from the work-injury in 2010 when the Veteran fell from atop a fence. These opinions are probative because they are based on an accurate medical history and in-person examination and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. There is no other competent medical opinion of record. While the Veteran believes his left knee disability is related to his service, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex as it requires interpretation of complicated diagnostic medical testing and understanding of internal physiological processes not visible by the natural senses. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the VA examiners' opinions than the Veteran's contrary lay assertions. He otherwise has not identified or submitted any evidence demonstrating his entitlement to service connection for a left knee disability. In summary, the Board finds that service connection for a left knee disability is not warranted. 3. Entitlement to TDIU is denied. The Veteran essentially contends he is unable to obtain and maintain substantially gainful employment due to all of his service-connected disabilities. The appeal period before the Board begins on March 27, 2012, one year prior to receipt of the increased rating claim for an eye disability. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). Service connection currently is in effect posttraumatic stress disorder (PTSD) (70 percent from March 27, 2013), left orbital floor fracture with double vision (0 percent from October 2, 2006, 20 percent from March 27, 2013, and 30 percent from August 1, 2017), right patellofemoral pain syndrome (10 percent from March 27, 2013), right knee limited extension (0 percent from March 27, 2013), and migraines (30 percent from October 16, 2014, and 0 percent from February 13, 2018). The combined evaluation is 0 percent from October 2, 2006, 80 percent from March 27, 2013, 90 percent from October 16, 2014, and 80 percent from February 13, 2018. The Veteran does not meet the schedular criteria for a TDIU prior to March 27, 2013. See 38 C.F.R. § 4.16(a). The question for the Board is whether there is evidence of unemployability due to his service-connected disabilities such that referral to the Director, Compensation Service, is warranted prior to March 27, 2013, and whether the Veteran is entitled to a TDIU on a schedular basis thereafter. The record evidence shows that an October 2012 occupational injury or illness report noted that the Veteran is employed as a cashier at AM/PM and he sustained a slip-and-fall on a newly mopped floor while holding a tray of food on October 2, 2012. A December 2012 private record noted the Veteran is a former cashier at AM/PM. He reported he lost his job 3 weeks ago. He stated he has been really stressed as he cannot find a job and this has been causing more discomfort in his back. He reported he is awaiting approval for additional therapy. In a February 2013 private examination by Dr. S.L., the Veteran stated he began employment with AM/PM as a gas station cashier in February 2010. His job duties included cashiering, stocking merchandise, cooking and baking, and cleaning duties. He stated that on October 2, 2012, he slipped on a wet floor and fell. He stated he was on light duty until November 25, 2012, when he was fired for a reason unrelated to the accident. In a March 2014 private evaluation, Dr. P.H. noted that according to a January 2014 deposition, the Veteran worked modified duty after the October 2012 back injury. It further noted that he worked until November 26, 2012, when he was terminated because he sold some alcohol after 2 am to customers and accepted a tip. In a December 2014 VA examination for eye conditions, the Veteran was diagnosed with orbital floor blowout fracture of left eye, diplopia related to orbital floor fracture, and pinguecula. The examiner noted the Veteran's eye condition impacts his ability to work in that his diplopia renders him unable to operate a forklift, or obtain a certification for forklift operation. In a February 2016 private examination for headaches by Dr. H.S., the Veteran was diagnosed with tension headaches. Dr. H.S. noted that the Veteran does not have characteristic prostrating attacks of migraine headache pain. The clinician noted that the headache condition impacts the Veteran's ability to work in that he experiences light and sound sensitivity, reduced power of concentration, and dizziness during a headache. It noted he has to lie down in a dark, quiet room. It also noted he would miss several days of work and require frequent unscheduled breaks throughout the day. A February 2016 private residual functional capacity evaluation by Dr. H.S. noted that the Veteran would miss 3 or more days of work per month due to his headaches; would need to leave early from the workplace 3 or more days per month due to headaches; and would not stay focused for at least 7 hours for an 8 hour workday for more than 3 days per month due to his headaches. Dr. H.S. noted that based on his complete knowledge of the Veteran's headaches and their effects, the Veteran would not be able to maintain substantially gainful employment. In a November 2016 private evaluation for headaches by Dr. N.J., the Veteran was diagnosed with migraine including migraine variants. It noted the Veteran experiences characteristic prostrating attacks of headaches once a month. It noted his headache condition did not impact his ability to work. A November 2016 private examination for knee conditions by Dr. N.J. noted that his left knee strain and right knee patellofemoral pain syndrome impact his ability to work. It noted the Veteran is mildly functionally limited with prolonged running, jumping, directly kneeling, and that activities that cause increased torque on the knee which could cause pain. Dr. N.J. also noted the Veteran can perform any type of occupational task without significant restrictions. In a November 2016 private examination for PTSD, clinician L.K. diagnosed the Veteran with PTSD and unspecified depressive disorder. The examiner summarized the summarized the Veteran's level of occupational and social impairment with regards to his PTSD and unspecified depressive disorder as occupational and social impairment with reduced reliability and productivity. A September 2017 private residual functional capacity evaluation by Dr. H.S. noted the Veteran would miss work due to mental problems 3 or more days a month. He would need to leave early from the workplace because of mental problems 3 or more days a month. And he may have trouble with concentration and would not stay focused to complete simple, repetitive tasks for at least 7 hours of an 8-hour workday for more than 3 days per month. Dr. H.S. noted that, if the Veteran were subject to the normal pressures and constructive criticisms of a job, he would respond inappropriately more than once a month in an angry manner but not actually become violent. A September 2017 private PTSD evaluation by Dr. H.H. noted a diagnosis of PTSD. Dr. H.H. summarized the Veteran's level of occupational and social impairment with regards to his PTSD as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. In an attachment, Dr. H.H. commented about the Veteran's employability that with poor interpersonal skills and workplace trust issues. This clinician stated that the Veteran would have an increase in paranoia and struggle with appropriate work interaction. She added that individuals with this mental health symptomatology could have higher distractibility, absenteeism, and emotional turmoil which is deemed inappropriate in the workplace. She also stated that the Veteran's troubling PTSD symptoms are preventing him from maintaining substantially gainful employment. A February 2018 VA examination for eye conditions noted diagnoses of orbital floor blowout fracture of left eye and diplopia secondary orbital fracture of left eye. It noted his eye condition impacts his ability to work. The examiner noted that the diplopia and the feeling that his eye gets stuck render the Veteran apprehensive about operating motor vehicles or heavy machinery which limit his ability to be gainfully employed. A February 2018 VA examination for headaches noted a diagnosis of migraine including migraine variants. The exam noted there are no characteristic prostrating attacks of headache pain and the Veteran's headache condition does not impact his ability to work. In a June 2018 private opinion, a vocational expert, Dr. S.B., noted excerpts of the Veteran's VA and private evaluations on file. Dr. S.B. noted that the Veteran is unable to perform his prior work as a telemarketer and a cashier. She noted that, while the work is physically within his capacities per the VA examiners, he is unable to sustain the contact with the public required to perform these tasks. She also noted that he is also unable to attend work regularly or concentrate to perform the semiskilled work tasks in these two positions. She stated that the Veteran is unable to perform any other work for which he is educated and/or trained to perform. She noted he has issues with social interaction, periods of social isolation, violent reactions, and inappropriate anger in environments including prior work settings. She also noted the Veteran is unable to maintain acceptable attendance or concentration for even simple work tasks. She noted he cannot perform demands of even unskilled work with minimal contract with others. She opined that the Veteran is totally and permanently precluded from performing work at a substantial gainful level due to the severity of this service-connected PTSD and unspecified depressive disorder, left orbital floor fracture with double vision secondary to left inferior rectus muscle injury, right patellofemoral pain syndrome, and right knee limited extension, and the record supports this finding as far back as the date of filing. A June 2018 private residual functional capacity evaluation by Dr. S.B. noted the Veteran would miss work due to his mental problems 3 or more days a month. He would need to leave early from the workplace because of his mental problems 3 or more days a month. And he may have trouble with concentration and would not stay focused to complete simple, repetitive tasks for at least 7 hours of an 8-hour workday for more than 3 days per month. Dr. S.B. noted that, if the Veteran were subject to the normal pressures and constructive criticisms of a job, he would respond in a violent manner about once a month. The Veteran's SSA records received in August 2019 shows he has severe impairment of degenerative disc disease of the lumbar spine from a work-related slip-and-fall injury in October 2012, and that he is disabled since November 26, 2012. An October 2019 VA examination for headaches noted a diagnosis of migraine including migraine variants. The exam noted there are no characteristic prostrating attacks of headache pain and the Veteran's headache condition does not impact his ability to work. In an October 2019 VA examination for back condition, the Veteran reported his occupations after service included telemarketing, gas station cashier, driver, and tree trimmer. He stated the last time he worked was in 2015-2016 in a warehouse. His October 2019 VA examination for knee conditions noted a diagnosis of left knee strain. It noted that his knee condition impacts his ability to work in that he has limitations with squatting and prolonged walking, especially with stairs. The examiner also noted though that occupations that are more sedentary such as desk/office work that entail sitting with periodic breaks to stand and walk should be tolerated. In an August 2020 VA Form 21-8940, the Veteran indicated that all of his service-connected disabilities prevented him from securing or following any substantially gainful occupation. He noted that the date his disabilities affected his full-time employment, the date he last worked full-time, and the date he became too disabled to work was November 23, 2012. The most he earned was $19,200 in 2012 while working as a cashier at an AM/PM gas station. He also worked temporarily for a manpower company from May to June 2016 on a full-time basis earning $2,080 per month and for a warehouse from May 2015 to August 2016 on a full-time basis earning $2,240 per month. He left his last job because of his disabilities. He had 1 year of college education. In February 2021, the Veteran provided a statement about his past work and the symptoms of his service-connected disabilities. He stated his last job was at a gas station from 2008 to 2012. He struggled with anxiety and paranoia while working there. He reported he was once robbed while working at night and it intensified his paranoia and PTSD. He noted he did ok interacting with customers but, when the store got crowded, he would get anxious and flustered. He had issues with controlling anger at work. He did not like taking orders or being instructed which made him feel insulted and he got reprimanded twice for his attitude and for talking back. He also reported issues with memory loss such as forgetting to change the gas prices or filling the cooler. He did not handle stress well and, when he had a lot of tasks to do, he got anxious and irritable. Due to his knee pain, he struggled with prolonged standing or kneeling down to stock the shelves at work. He could not lift and carry over 50 pounds so there were tasks he could not do. His knee would give out on him sometimes and would fall at work. His knee pain added to his stress and irritability. He reported getting migraines 2-3 times a week while working there. He would have to leave work early or call in sick 4-5 times per month due to his migraines. When he gets a migraine, he gets dizzy, and has body spasms and visions issues. He is sensitive to light and sound and just could not function to work. He struggled to see the numbers on the register due to migraines and vision issues. The Board finds that the preponderance of the evidence is against granting the Veteran's TDIU claim, including on an extraschedular basis prior to March 27, 2013. The evidence of record does not show functional impairment caused by the Veteran's service-connected disabilities, alone or in combination, resulted in an inability to secure and maintain a substantially gainful occupation during the appeal period. With respect to the economic component in Ray, the Veteran noted on his August 2020 VA Form 21-8940 that he last worked in November 2012 and he held a job at a warehouse from May 2015 to August 2016 on a full-time basis earning $2,240 per month. Thus, the economic component of Ray has been met from December 2012 to April 2015 and effective September 2016. With respect to the non-economic component in Ray, while the evidence indicates that the service-connected disabilities impact his ability to perform certain physical functions, it does not indicate that he is unable to perform any occupational tasks. His right knee condition may prevent him from performing occupational duties that involve strenuous physical labor, or excessive walking or standing. His eye disability could limit his ability to operate heavy machinery. The evidence does not reflect that he would be unable to perform occupational duties in an unskilled or semi-skilled position that does not involve strenuous physical movement or operation of heavy machinery. For instance, he could secure and maintain substantially gainful employment in positions in an office-based setting performing light office work, light custodial work, entry level administrative work, or telemarketing. He would be able to move around and sit as needed in those positions and avoid pressure on his knee. He would not need to operate a heavy machinery. The Board does not find his service-connected headaches prevent him from securing or maintaining substantially gainful employment. Dr. H.S. opined in his February 2016 evaluation that the Veteran would not be able to maintain substantially gainful employment due to his headaches; however, the rest of this evaluation and other private and VA evaluations do not support the conclusion reached by this clinician. Dr. H.S. noted certain limitations from the headaches (light and sound sensitivity, reduced power of concentration; dizziness, a need to lie down during an episode) but he did not explain the Veteran cannot work due to his headaches. Dr. H.S. also stated that the Veteran does not have any characteristic prostrating attacks of migraine headache pain. The Veteran also was rated only at 30 percent disabling for the service-connected headaches at the time of Dr. H.S.'s evaluation. Thus, it is unclear how Dr. H.S. determined that the Veteran would not be able to maintain substantially gainful employment due to his service-connected headaches. The November 2016 private exam noted that the Veteran experienced characteristic prostrating attacks of headache pain only once a month and his headaches did not impact his ability to work. The February 2018 and October 2019 VA examiners determined that the service-connected headaches did not impact his ability to work. In other words, the Board finds that, while the service-connected headaches may cause some physical limitations, they do not prevent the Veteran from securing or maintaining substantially gainful employment. With regard to the mental limitations imposed by his service-connected disabilities, the Veteran's experiences, at worst, occupational and social impairment with deficiencies in most areas. This level of impairment is not consistent with a finding that the service-connected PTSD precluded the ability to perform mental actions consistent with the Veteran's work history and experience performing unskilled/semi-skilled employment. While Dr. H.H. noted in the September 2017 evaluation that the Veteran's troubling PTSD symptoms prevent him from maintaining substantially gainful employment, the overall assessment indicated that he would experience only significant hardships from increased paranoia and difficulty in social interaction. This clinician did not conclude that the Veteran had total occupational and social impairment as a result of his service-connected PTSD. Dr. L.K. summarized the Veteran's level of occupational and social impairment due to his service-connected PTSD in November 2016 as occupational and social impairment with reduced reliability and productivity. In short, the Board finds that, while the records demonstrate significant occupational and social impairment as a result of his service-connected PTSD, they do not show that he is precluded from securing or maintaining a substantially gainful occupation. The evidence of record does not show functional impairment caused by the service-connected disabilities prevented the Veteran from securing and maintaining a substantially gainful occupation. He otherwise has not identified or submitted any evidence demonstrating his entitlement to a TDIU. In summary, the Board finds that the criteria for a TDIU have not been met. MICHAEL T. OSBORNE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jake Choi, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.