Citation Nr: 21006443 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 14-18 118 DATE: February 4, 2021 ORDER Entitlement to a rating in excess of 20 percent prior to December 19, 2011, and a rating in excess of 30 percent from December 19, 2011, for avascular necrosis, right shoulder, is denied. Entitlement to a rating in excess of 20 percent for avascular necrosis, left shoulder, is denied. Entitlement to a rating in excess of 10 percent prior to August 20, 2020, and a rating in excess of 30 percent from August 20, 2020, for median neuropathy, right upper extremity, is denied. Entitlement to a rating in excess of 10 percent prior to August 20, 2020, and a rating in excess of 20 percent from August 20, 2020, for median neuropathy, left upper extremity, is denied. Entitlement to a total disability based on individual unemployability (TDIU) due to service-connected disabilities, effective prior to December 16, 2011, is denied. Entitlement to a TDIU, effective from December 16, 2011, is moot and is dismissed. FINDINGS OF FACT 1. Effective prior to December 19, 2011, the Veteran’s avascular necrosis, right shoulder, was manifested by pain and limitation of motion of the major extremity no worse than to shoulder level. 2. Effective from December 19, 2011, the Veteran’s avascular necrosis, right shoulder, is manifested by pain and limitation of motion of the major extremity, no worse than to midway between side and shoulder level. 3. The Veteran’s avascular necrosis, left shoulder, is manifested by pain and limitation of motion of the minor extremity, no worse than midway between side and shoulder level. 4. Effective prior to August 20, 2020, the Veteran’s median neuropathy, right upper extremity, was manifested by no more than mild incomplete paralysis of the major extremity. 5. Effective from August 20, 2020, the Veteran’s median neuropathy, right upper extremity, is manifest by no more than moderate incomplete paralysis of the major extremity. 6. Effective prior to August 20, 2020, the Veteran’s median neuropathy, left upper extremity, was manifested by no more than mild incomplete paralysis of the minor extremity. 7. Effective from August 20, 2020, the Veteran’s median neuropathy, left upper extremity, is manifest by no more than moderate incomplete paralysis of the minor extremity. 8. Effective prior to December 16, 2011, the Veteran's service-connected disabilities, alone, did not render him unable to secure or follow substantially gainful employment. 9. Effective from December 16, 2011, the Veteran's service-connected disabilities have resulted in a 100 percent schedular rating. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent prior to December 19, 2011, and a rating in excess of 30 percent from December 19, 2011, for avascular necrosis, right shoulder, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes (DCs) 5010, 5201 2. The criteria for a rating in excess of 20 percent for avascular necrosis, left shoulder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5010, 5201. 3. The criteria for a rating in excess of 10 percent prior to August 20, 2020, and a rating in excess of 30 percent from August 20, 2020, for median neuropathy, right upper extremity, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DCs 8515, 8615. 4. The criteria for a rating in excess of 10 percent prior to August 20, 2020, and a rating in excess of 20 percent from August 20, 2020, for median neuropathy, left upper extremity, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DCs 8515, 8615. 5. Effective prior to December 16, 2011, the criteria for a TDIU were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19. 6. Effective from December 16, 2011, the issue of entitlement to a TDIU is moot. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1971 to September 1975, and from February 1978 to January 1985. He also served in the Mississippi Army National Guard from February 1985 to February 1994. In August 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. In December 2017, the Board remanded this matter for further development. At that time, the claims on appeal included entitlement to higher ratings for median neuropathy of the right wrist and left wrist, associated with status post cold injury right/left hand, with residuals. As noted above, the issues have been recharacterized as entitlement to higher ratings for median neuropathy of the right upper extremity and left upper extremity, associated with status-post cold-injury right/left hand, with residuals. Increased Rating Disability ratings are determined by application of the VA Schedule for Rating Disabilities, which is based on average impairment of earning capacity. Separate diagnostic codes identify various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 1. Entitlement to a rating in excess of 20 percent prior to December 19, 2011, and a rating in excess of 30 percent from December 19, 2011, for avascular necrosis, right shoulder, and entitlement to a rating in excess of 20 percent for avascular necrosis, left shoulder. The Veteran contends that he is entitled to higher ratings prior to, and effective from, December 19, 2011, for avascular necrosis of his right (major) shoulder, and a higher rating for avascular necrosis of his left (minor) shoulder. After review of the record, the Board concludes that higher ratings are not warranted, at any point, for the service-connected avascular necrosis of the right and left shoulders. The Veteran’s avascular necrosis of the right and left shoulders has been rated under Diagnostic Code (DC) 5210 and DC 5201. Arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis, which will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, DCs 5003, 5010. DC 5201 provides that limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from the side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, DC 5201. Review of the record shows that at a VA examination in October 2010, the Veteran reported daily bilateral shoulder pain, worsened with weather and activity, and particularly overhead activity. He had trouble sleeping due to shoulder pain, and reported that shoulder pain affected his activities of daily living. Examination of the shoulders revealed no erythema, swelling, or tenderness. Active forward flexion and abduction was to 90 degrees in each shoulder. Good strength was shown. Examination revealed positive impingement signs and pain with attempted crossbody adduction. No additional pain, weakness, or limitation of motion was shown with resistance or after 5 repetitions. The examiner opined the Veteran had significantly decreased range of motion of the shoulders with moderate pain. The examiner opined it was conceivable the Veteran’s pain could worsen and further limit function, but that it was not feasible to express this in terms of additional loss of motion as this could not be determined with any degree of medical certainty. VA treatment records show that in May 2011, the Veteran’s shoulders range of motion on abduction and flexion was to 70 degrees. In December 2011, severe restriction of the shoulders was noted, the impression was severe degenerative joint disease, and the plan was to continue conservative methods. After review of the record, the Board concludes the preponderance of the evidence is against a rating in excess of 20 percent prior to December 19, 2011, for avascular necrosis, right shoulder, under DC 5201. In that regard, the Board acknowledges the Veteran's lay reports of pain and limitations on activities, and that there was functional loss due to pain and limited range of motion. However, range of motion testing showed that flexion and abduction were, at worst, limited to 70 degrees. Additionally, even though a VA examiner opined that it was conceivable the Veteran’s pain could worsen and further limit function, it was also noted that it was not feasible to express this in terms of additional loss of motion. Finally, even considering the Veteran's reports of pain and noted functional loss, as well as limits on activities, the disability rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a, and the findings of pain, functional loss, and limitations on activities do not more nearly approximate limitation of motion of the arm midway between side and shoulder level of the major extremity. Accordingly, the Board finds that a rating higher than 20 percent for the Veteran's avascular necrosis, right shoulder disability, is not warranted based on functional impairment at any time during the appeal period (prior to December 19, 2011). 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). With regard to a higher rating for avascular necrosis, right shoulder, effective from December 19, 2011, the record shows that on a VA examination in May 2012, the Veteran reported severe right and left shoulder pain that was worsening. He reported flare-ups impacting functioning, noting that pain was worse with activity of the upper extremities. Forward flexion and abduction of the shoulders was to 40 degrees, with pain. Repetitive-use testing was performed, with no additional loss of flexion of the right or left shoulder or abduction of the left shoulder, but abduction of the right shoulder was limited to 30 degrees after 3 repetitions. It was also noted that he experienced functional impairment of the shoulders due to less movement than normal, weakened movement, excess fatigability, pain on movement, and swelling. Examination of the shoulders revealed tenderness, guarding, slightly reduced muscle strength (4/5), but no ankylosis. There was a history of mechanical symptoms for both shoulders, but no recurrent dislocation or subluxation. The examiner opined that the Veteran’s right and left shoulder conditions impacted his ability to work, noting he was severely limited by pain. VA treatment records show that in March 2013, the Veteran was seen in the emergency department for increased right shoulder pain. Examination revealed range of right shoulder motion was slightly limited due to pain. A week and a half later, in March 2013, he was seen for follow-up, and examination revealed right and left shoulder abduction was limited to 90 degrees. In October 2013, he was seen for shoulder pain, and examination revealed limited abduction and flexion due to arthritic changes. In March 2014, he had continued pain in the shoulders, and examination revealed severe limitation of the shoulders. In March 2016, he was seen for pain on abduction and flexion of the shoulders. In August 2017, the Veteran testified that because of his right and left shoulder condition, he could not do much overhead movement and that when he moved his shoulder it cracked and would only go so far. On a VA examination in August 2020, the Veteran reported chronic shoulder pain, limited range of motion, stiffness, and popping and locking. He reported daily moderate flare-ups of the shoulders, precipitated by daily activities, lasting 24 hours, and alleviated by rest. He had difficulties with heavy lifting, overhead reaching, and pushing and pulling objects. Range of right shoulder motion was to 60 degrees on flexion and abduction, and left shoulder motion was to 60 degrees on flexion and to 40 degrees on abduction, with pain on all ranges of motion. The examiner indicated that the pain and limited motion contributed to loss of function with regard to overhead reaching, and lifting and carrying heavy objects. Pain was noted with weight-bearing, and there was crepitus in both shoulders. Repetitive use testing was possible, but with no additional loss of function or range of motion. The examiner opined that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time and with flare-ups, and that pain, weakness, and lack of endurance significantly limited functional ability of the shoulders with repeated use over a period of time. Muscle strength testing revealed slightly decreased (4/5) strength on flexion and abduction. No atrophy was noted. Shoulder instability, dislocation, or labral pathology was suspected, and a history of mechanical symptoms was noted in both shoulders. The examiner opined that the Veteran’s shoulder disabilities impacted his ability to work, including tasks requiring repetitive heavy lifting and overhead reaching, and that pushing and pulling aggravated the condition due to pain and stiffness. After review of the record, the Board finds that the preponderance of the evidence is against a rating in excess of 30 percent, from December 19, 2011, for avascular necrosis, right shoulder, under DC 5201. The Board acknowledges the Veteran's lay reports of shoulder pain, daily flare-ups, stiffness, popping, and locking of the joint, and limitations on activities, and that there was functional loss due to pain and limited range of motion. Flexion was, however, at worst, limited to 40 degrees, and abduction was also, at worst, limited to 40 degrees, but further limited to 30 degrees after 3 repetitions of motion. Thus, the Board concludes that even considering the Veteran's reports of pain and noted functional loss, as well as limits on activities, the disability rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a, and the findings of pain, functional loss, and limitations on activities does not more nearly approximate limitation of motion of the arm to 25 degrees from the side of the major extremity. Considering the foregoing, the Board finds that a rating higher than the 30 percent rating, effective from December 19, 2011, for avascular necrosis, right shoulder disability, is not warranted based on functional impairment at any time during the appeal period. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, supra. Finally, the Veteran also contends that he is entitled to a rating in excess of 20 percent for avascular necrosis, left shoulder. In that regard, the Board acknowledges his lay reports of left shoulder pain, daily flare-ups, stiffness, popping, and locking of the joint, and limitations on activities, and that there was functional loss due to pain and limited range of motion. However, left shoulder flexion and abduction were, at worst, limited to 40 degrees, with pain. Thus, the Board concludes that even considering the Veteran's reports of pain and noted functional loss, as well as the limits on his activities, including overhead activities, the disability rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a, and the findings of pain, functional loss, and limitations on activities does not more nearly approximate limitation of motion of the arm to 25 degrees from the side of the major extremity. Considering the foregoing, the Board finds that a rating higher than 20 percent rating, for avascular necrosis, left shoulder, is not warranted based on functional impairment at any time during the appeal period. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, supra. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder provide for higher ratings for the right shoulder prior to or effective from December 19, 2011, or for the left shoulder. The evidence, however, does not reflect that a higher rating is warranted as there is no evidence of ankylosis, nor impairment such as nonunion, malunion or recurrent dislocation of the humerus, to warrant consideration under DCs 5200-5202. A higher rating is also not warranted under DC 5203 as impairment of the clavicle or scapula is not shown and he is already in receipt of the maximum rating under this code. The Board concludes that the preponderance of the evidence is against the appeal for a rating in excess of 20 percent, prior to December 19, 2011, and a rating in excess of 30 percent from December 19, 2011, for avascular necrosis, right shoulder, and a rating in excess of 20 percent for avascular necrosis, left shoulder. 2. Entitlement to a rating in excess of 10 percent prior to August 20, 2020, and a rating in excess of 30 percent from August 20, 2020, for median neuropathy, right upper extremity, and median neuropathy, left upper extremity. The Veteran contends he is entitled to higher ratings prior to, and effective from, August 20, 2020, for median neuropathy of the right and left upper extremities. After review of the record, the Board concludes that higher ratings are not warranted for median neuropathy of the right or left upper extremity, at any point prior to, or effective from, August 20, 2020. The Veteran's service-connected median neuropathy of the bilateral upper extremities has been rated under DC 8615 prior to August 20, 2020, for neuritis of the median nerve, and under DC 8515 from August 20, 2020. Neuritis is to be rated on the scale provided for injury of the nerve involved with a maximum equal to severe incomplete paralysis. 38 C.F.R. § 4.123. Where neuritis is not characterized by organic changes, such as loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, the maximum rating which may be assigned will be that of moderate incomplete paralysis. Id. The scale for paralysis of the median nerve provides that a 10 percent rating is assigned for mild incomplete paralysis of either the major or minor extremity. A 20 percent rating is assigned for moderate incomplete paralysis of the minor extremity and a 30 percent rating is assigned where there is moderate incomplete paralysis of the major extremity. A 40 percent rating is assigned for severe incomplete paralysis of the minor extremity and a 50 percent rating is assigned for severe incomplete paralysis of the major extremity. A 60 percent rating is assigned for complete paralysis of the minor extremity and a 70 percent rating is assigned for complete paralysis of the major extremity. Complete paralysis of the median nerve is characterized by the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand; pronation incomplete and defective, absence of flexion of the index finger and feeble flexion of the middle finger, inability to make a fist, index and middle fingers remaining extended; inability to flex the distal phalanx of the thumb, defective opposition and abduction of the thumb at right angles to the palm; flexion of the wrist weakened; and pain with trophic disturbances. 38 C.F.R. § 4.124a, DC 8515. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). Review of the record includes a March 2010 VA treatment record showing that the Veteran was seen for severe right wrist pain; examination revealed swelling, limited motion, and severe crepitus. The impression was severe arthritis which markedly limited use of the hand and arm. A wrist fusion was suggested. On a VA examination in March 2010, the Veteran reported right and left-hand pain, numbness, tingling, weakness, swelling, and decreased/loss of sensation. He reported limited use of his hands which affected his ability to work. Examination revealed pain, no weakness or atrophy, decreased light touch and pinprick sensation in both hands, and radial pulses were 2+ bilaterally. On a VA examination in May 2010, the Veteran reported right and left hand pain and soft tissue swelling, with associated shooting pains to the fingers. He reported pain with movement of the wrist, as well as weakness, giving out, stiffness, numbness, and tingling at all fingers. He also reported flare-ups, 10 to 12 times a day, precipitated by wrist flexion, lasting one hour on the right, but improved by repositioning the wrist, and lasting momentarily on the left. He reported that his hand pain and symptoms severely affected his ability to do basic daily activities such as grooming, eating, dressing, bathing, and driving. Examination of the wrists revealed positive Tinel and Phalen’s tests and stable ligaments. Examination of the wrists and hands revealed no additional pain, weakness, or loss of motion after five repetitions, 5/5 muscle strength, intact sensation, and radial pulses 2+ bilaterally. Examination of the hands revealed normal skin color and temperature, and no swelling, effusion, or tenderness. The examiner opined that the Veteran’s bilateral wrist/hand conditions could be further limited in function after strenuous and repetitive activities such as physical labor, but that it was not feasible to express any of this in terms of additional limitation of motions as this could not be determined with any degree of medical certainty. On a VA examination in October 2010, the Veteran reported pain to the dorsum of the hands and radial aspect of the wrists. He had occasional hand swelling, and flare-ups with shooting pain at the wrists, extending to the fingers. Examination of his wrists and hands revealed normal skin color and temperature, with no significant swelling or tenderness. Examination revealed negative Tinel’s and Phalen’s tests bilaterally, intact sensation to light touch and intact motor function of the medial, radial and ulnar nerves, and no significant points of tenderness to palpation of the fingers or hands. There were no overlying skin changes. There was mild stiffness and discomfort with movement of the fingers, but no additional pain, weakness, or loss of motion with resistance or after 5 repetitions. On a VA peripheral nerves examination in January 2012, the Veteran responded “no” to having constant pain of the upper extremities, but did report intermittent moderate pain (usually dull), moderate paresthesias and/or dysesthesias, and moderate numbness of the upper extremities. Poor grip strength was noted. Muscle strength of the wrists on flexion/extension, and with gripping and pinching (thumb to index finger) movements was normal (5/5). No atrophy was noted. Reflexes of the upper extremities was normal. Sensory examination revealed decreased sensation of the hands and fingers for light touch. No trophic changes were noted. Testing for the median nerve was indicated and performed, but revealed negative Tinel’s and Phalen’s signs bilaterally. Radial, median, and ulnar nerve testing was normal on the right and left. On a VA cold injury residuals examination in May 2012, the Veteran reported having poor grip in his hands over the years, but was able to take care of his activities of daily living. It was noted that he refused to make a fist as he could not make a fist due to weakness in his hands. VA treatment records show that in March 2013, the Veteran was seen in the emergency department for increased right wrist pain, and examination revealed right wrist osteohypeplasia, with limited range of motion and joint pain. Later in March 2013, he was seen for follow-up for right wrist pain. Examination revealed mild right wrist swelling and tenderness with severely decreased range of wrist motion. He was unable to wear the right wrist brace he was given. In March 2016, he was seen for multiple joint arthritis with painful range of motion of the hands. In August 2017, the Veteran testified he had trouble lifting his hands and wrists, and had trouble driving for a long trip because it made his hands go dead. On an August 2020 VA examination, the Veteran reported difficulty with heavy lifting, overhead reaching, prolonged typing, writing, gripping/handling, and pushing/pulling objects. Current symptoms included constant numbness and tingling with a burning sensation in the wrists and fingers, decreased grip strength, and weakness. Peripheral nerve symptoms included constant moderate pain, paresthesias and/or dysesthesia, and numbness in both upper extremities. Muscle strength testing revealed slightly decreased (4/5) grip and pinch strength (thumb to index finger) in both hands. No atrophy or trophic changes were noted. Sensory examination of the hands and fingers was normal. A positive Tinel's sign was noted for the right and left median nerve. The examiner opined that the Veteran had moderate incomplete paralysis of the right and left median nerves. With regard to the earlier staged period, prior to August 20, 2020, a higher 20 percent rating for each upper extremity requires a finding that the Veteran's median neuropathy was, or approximated, moderate in severity. After review of the record for that period, however, the Board finds that the competent medical evidence of record does not demonstrate that the severity of the Veteran's condition, for either the right or the left upper extremity, can be considered moderately severe. Here, VA examinations show that the Veteran reported having right and left hand/wrist pain, limited motion, numbness, tingling, weakness, swelling, stiffness, and flare-ups with shooting pain. He also reported having a poor grip and difficulty making a fist and lifting his hands and wrists. He reported that due to right and left hand/wrist pain and other symptoms, he had difficulties with basic daily activities, including grooming, eating, dressing, bathing, and driving. VA examinations during this period, however, showed no atrophy or weakness, normal muscle strength, no significant tenderness, no trophic or skin changes, and normal reflexes. While the VA examiner in May 2010 noted intact sensation in the Veteran’s wrists and hands, in January 2012 the VA examiner noted that the Veteran had decreased sensation of the hands and fingers, but radial, median, and ulnar nerve testing was normal in both upper extremities. The Board therefore finds the VA examinations to be highly probative in demonstrating that the Veteran's condition for this period, with regards to his upper extremities, to be at worst mild. Here, neither the VA examination of record, nor any contemporaneous VA treatment record for this period show that the Veteran's condition could be considered moderate in nature. Further, the Board finds the competent evidence of record does not suggest that the Veteran's neuropathies limited him functionally more than would be contemplated by the currently assigned 10 percent ratings at any point prior to August 20, 2020. As such, the Board must find that the preponderance of evidence is against the findings for a higher rating for this earlier staged period. With regards to the latter period, from August 20, 2020, a higher rating for the right (major) extremity and left (minor) extremity is only warranted when such disability is considered severe. Here, the Board acknowledges the Veteran’s report of difficulty with heavy lifting, overhead reaching, prolonged typing, writing, gripping/handling, and pushing/pulling objects, and his symptoms including pain, constant numbness, tingling, burning sensation in the wrists and fingers, decreased grip strength, and weakness. However, the VA examination in August 2020, on which the staged higher ratings were based, noted no condition regarding either of the Veteran's upper extremities to be severe, and characterized his symptoms, including constant pain and numbness, as moderate. Moreover, he exhibited only slightly decreased grip and pinch strength, no atrophy or trophic changes were noted, and sensory examination of the hands/fingers was normal. As such, the Board concludes that from August 20, 2020, the competent evidence shows that the Veteran’s median neuropathy of the bilateral upper extremities has been manifested by no more than moderate incomplete paralysis, and thus an evaluation in excess of 20 percent for the left upper extremity and 30 percent for the right upper extremity, is not warranted. 3. Entitlement to a TDIU. The Veteran contends he is unable to secure or maintain substantially gainful employment due to his service-connected hips, wrists, and shoulders. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. Id. Review of the record shows that the Veteran’s service-connected disabilities include left hip arthritis, status post total hip replacement and right hip arthritis, status post total hip replacement, each rated 50 percent from December 16, 2011; avascular necrosis, right shoulder, rated 20 percent from November 09, 2009, and 30 percent from December 19, 2011; median neuropathy, right upper extremity, rated 10 percent from November 09, 2009, and 30 percent from August 20, 2020; avascular necrosis, left shoulder, rated 20 percent from November 09, 2009; median neuropathy, left upper extremity, rated 10 percent from November 09, 2009, and 20 percent from August 20, 2020; status post cold injury, right hand, rated 10 percent from July 19, 2001; status post cold injury, left hand, rated 10 percent from January 26, 2009; and surgical scars, status post right and left total hip replacements, each rated 0 percent from December 16, 2011. The combined rating for his service-connected disabilities was 60 percent from November 09, 2009, incorporating a bilateral factor of 5.8 percent for diagnostic codes 7122, 8615, 5201; and 100 percent from December 16, 2011, incorporating a bilateral factor of 8.9 percent for diagnostic codes 7122, 8615, 5201, 5054. Prior to December 16, 2011, even with consideration of the bilateral upper extremity disabilities and bilateral factor, the Veteran’s service-connected disabilities did not meet the regulatory requirements of 38 C.F.R. § 4.16(a) for a schedular award of a TDIU. A total disability rating may be assigned to veterans who fail to meet the schedular standards under 38 C.F.R. § 4.16. Rating boards should refer to the Director, Compensation and Pension Service, for extraschedular consideration, all cases where the veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability, but fails to meet the percentage standards set forth in section 4.16(a). 38 C.F.R. § 4.16 (b). Where, as here, the Veteran fails to meet the threshold minimum percentage standards in 38 C.F.R. § 4.16(a), prior to December 16, 2011, the Board must consider whether referral for extraschedular consideration is warranted. As noted above, from December 16, 2011, a combined 100 percent rating has been in effect. A TDIU is considered a lesser benefit than the 100 percent scheduler rating, and the grant of a 100 percent scheduler rating generally renders moot the issue of entitlement to a TDIU for the period when the 100 percent rating is in effect. A 100 percent disability rating does not necessarily render the issue of a TDIU moot. In in Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008), the United States Court of Appeals for Veterans Claims (Court) determined there could be a situation where a veteran has a schedular total rating and could also be entitled to a TDIU for purposes of meeting the requirements for special monthly compensation (SMC) pursuant to 38 U.S.C. § 1114 (s). SMC is warranted for housebound status if a veteran has a single service-connected disability rated as total and additional service-connected disabilities that are independently rated at more than 60 percent combined. A TDIU satisfies the total (100 percent) rating requirement if the TDIU evaluation was, or can be, predicated upon a single disability and there exists additional disability or disabilities independently ratable at 60 percent or more. While 38 C.F.R. § 4.16(a) provides for treatment of multiple disabilities as "one disability" in certain circumstances (such as disabilities resulting from a common etiology or injury), the decision to treat multiple disabilities as one is specifically limited to TDIU ratings and 38 C.F.R. § 4.16(a). A "TDIU rating that is based on multiple disabilities cannot satisfy the section 1114(s) requirements of 'a service-connected disability' because that requirement must be met by a single disability." Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2010). As noted above, effective December 16, 2011, the Veteran has a combined 100 percent schedular rating. He does not, however, have a single service-connected disability rated as total, nor does he have a single disability rated at 60 percent or more, such that entitlement to a TDIU cannot be established based on a single disability. 38 C.F.R. § 4.16(a). This situation is distinguished from Bradley; as the Veteran is already in receipt of a combined schedular rating of 100 percent, the issue of entitlement to TDIU, prior to December 16, 2011, is moot. Herlehy v. Principi, 15 Vet. App. 33, 35 (2001). As for the period prior to December 16, 2011, after weighing the medical and lay evidence of record, the Board finds that the criteria for referral of a TDIU on an extraschedular basis were not met. Review of the record includes VA treatment records which show that in March 1999, the Veteran reported he worked as a factory maintenance man, but was told that due to his arthritic hip he needed to find another line of work to avoid the lifting and climbing that was part of his current job. It was noted that he had 2 years of college with an agriculture major and wanted to train for that line of work. Records from the Social Security Administration (SSA) show that the Veteran receives disability benefits, effective July 2006, for a primary diagnosis of status post bilateral total hip replacement and glaucoma. VA treatment records show that in June 2009, the Veteran reported he coached boxing at the police academy, and was currently in school, but also had his own farm and was a pastor at two churches. He occasionally complained of buttocks pain if he did a lot of cycling at the gym or if he was taking care of his farm animals, including carrying 5-gallon buckets full of feed. Received in November 2009 was an Application for Increased Compensation based on Unemployability (VA Form 21-8940), in which the Veteran reported that his service-connected hand injury prevented him from securing or following any substantially gainful occupation. He reported he worked 30 hours per week at a department store from 2004 through 2006, but currently worked 4 hours a week, since 1995, as a pastor at a church, and did farming for 12 hours a week, since 2004. He had applied for factory work in September 2009. His highest level of education completed was one year of college. He attended community college from 1994 through 2007 for agriculture. He did not complete the parts of the form that asked the date his disability affected full time work, the date he last worked full time, the date he became too disabled to work, the most he ever earned in one year, including the year that happened and his occupation was during that year. In a statement received in November 2009, the Veteran reported that due to his service-connected hand condition and hip surgeries, he was unable to work. Received in December 2009 was a letter from a VA physician who noted following the Veteran for bilateral hip replacements and bilateral shoulder arthritis, which limited his ability to stand, walk, and perform overhead activity. The VA physician opined that the Veteran was unable to perform any jobs for which he was trained. A March 2010 VA treatment record noted an impression of severe arthritis which markedly limited the Veteran’s use of his hands and arms. The VA physician opined that with the combination of hips and wrist, the Veteran was markedly limited as far as his previous employment. On a VA examination in May 2010, the Veteran reported that after service he was a mechanic for 26 years, and that his cold injury residuals of the hands affected his job because in the winter he had difficulty working with tools while wearing gloves. He reported limited use of hands which affected his ability to work, and that he used to be a mechanic until 2000. He was currently going to school to train in agriculture economy, and did limited farming. He reported he was self-employed, had difficulty using computers, operating tractors, and driving, and could not do mechanic work, physical work, or farming. On another VA examination in May 2010, the Veteran reported he was self-employed as a farmer and pastor for the last 4 years, and stated that his activities as a farmer caused hands to swell and itch, and that he had decreased ability to drive tractors and heavy equipment and to utilize handheld tools. Received in June 2010 was a Request for Employment Information form containing information regarding the Veteran's job as a pastor, indicating he started working in August 2008 and worked every other Sunday. Another Request for Employment Information form noted the Veteran worked as a salesclerk at Reed’s Department Store from September 2005 to May 2006 for 37.5 hours a week, but that he left that job for another job. On a VA examination in October 2010, the Veteran reported he worked as a pastor and a self-employed farmer. He reported shoulder pain with lifting and overhead type activities that limited him from doing farm work. It was noted that his hand symptoms affected his ability to do his farm work, and that working as a farmer caused his hands to swell particularly in the cold weather months. Records from Vocational Rehabilitation & Employment (VR&E) program show that the Veteran applied for benefits in November 2010. At that time, he indicated having worked part time as a pastor since 1995, and part time as a small farmer since 2004. In November 2010, achievement of the Veteran’s vocational goal was reasonably feasible. In December 2010, entitlement to an evaluation for vocational rehabilitation services was established. In a Chapter 31 Initial Evaluation Report it was noted that the Veteran was a pastor of Clear Springs CME Church, and he expressed an interest in pursuing VR&E services to assist in obtaining financial assistance to attend college. It was also noted that it was his intention to get a degree in agriculture and return to the competitive employment. Prior to December 16, 2011, the Veteran's service-connected disabilities, including left and right hip disabilities; avascular necrosis, right and left shoulder; median neuropathy, right and left upper extremity, and status post cold injury, right and left hands, clearly affected his ability to work. In that regard, SSA records show that the Veteran receives disability benefits, effective July 2006, for status post bilateral total hip replacement and glaucoma. Further VA physicians opined in 2009, 2010, and 2011 that that the Veteran was unable to perform any jobs for which he was trained, that he was markedly limited for his prior employment, and that he was totally unemployable. However, in his application for a TDIU he did not indicate when he last worked full time, nor did he indicate when he became too disabled to work. The record shows that the Veteran worked as a pastor, apparently in a part time capacity, since at least 2005, and that he was a small farmer for a few hours a week, but it appears these jobs were both in a part time capacity, and may be considered marginal employment. However, while the Veteran clearly experienced a degree of occupational impairment from his service-connected disabilities prior to December 16, 2011, the competent evidence of record preponderates against a finding that he was unemployable due solely to his service-connected disabilities. In that regard, the record shows that he was granted SSA disability benefits in part due to his non-service-connected glaucoma. While SSA determinations are not binding on the Board, the decision and documents on which it is based are relevant evidence. See Anderson v. Brown, 5 Vet. App. 347, 354 (1993). Further, the Board notes that the Veteran did not completely report his employment history, including noting when he last worked full time, but it appears that this occurred in 2006 when he left his job at a department store. Additionally, in 2010, the Veteran was granted VR&E benefits, based on a finding that he has a "serious employment handicap" and the achievement of a vocational goal was “reasonably feasible". Thus, the Veteran was found to be sufficiently disabled in order to qualify for services, but it was reasonably feasible that he would achieve a vocational goal as a result of services. For the Veteran to participate in VR&E services, a determination was made that obtaining a vocational goal was feasible, meaning gainful employment status was feasible. Although such determination is not definitive in the matter of entitlement to a TDIU, it is at least inconsistent with a claim of TDIU, which requires an inability to secure or follow substantially gainful employment. In conclusion, while the Board does not wish to minimize the nature and extent of the Veteran's service-connected disabilities, the evidence of record prior to December 16, 2011, simply does not support the claim that his service-connected disabilities alone were sufficient to produce unemployability for that period. To the extent the Veteran was limited by his service-connected hips, wrists, and shoulders, any such limitation was contemplated in, and adequately compensated by, the disability ratings assigned. Accordingly, based on the foregoing, prior to December 16, 2011, the criteria for referral for a TDIU are not met. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Casula 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.