Citation Nr: 21007049 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 13-18 571A DATE: February 8, 2021 ORDER Entitlement to a rating in excess of 30 percent prior to May 10, 2019 and in excess of 50 percent thereafter, for service-connected posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for a bilateral knee disorder is denied. Entitlement to service connection for a bilateral foot disorder is denied. Entitlement to service connection for sleep apnea as secondary to service-connected PTSD is granted. Entitlement to a total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. Prior to May 10, 2019, the Veteran's PTSD was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. As of May 10, 2019, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity. 3. The Veteran’s bilateral knee disability was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 4. The Veteran’s bilateral foot disability was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 5. The Veteran’s sleep apnea is proximately due to service-connected PTSD. 6. The evidence of record does not show that the Veteran was unable to obtain or maintain substantially gainful employment as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent prior to May 10, 2019 and in excess of 50 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for service connection for a bilateral knee disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for a bilateral foot disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for sleep apnea, as secondary to the service-connected PTSD, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1967 to July 1969 with service in Vietnam from January to August 1968. The Veteran is a recipient of the Combat Action Ribbon. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, and the VA Appeals Management Center (AMC). A Board hearing before the undersigned Veterans Law Judge was held in April 2018 in Washington, District of Columbia. A transcript of the hearing has been associated with the claims file. This matter was remanded by the Board for additional development in August 2018 for additional development. In a July 2020 rating decision, the RO granted service connection for a right shoulder disability and tinea pedis; these issues are no longer on appeal and are thus not considered herein. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2018). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2018). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptom that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007). 1. Entitlement to a rating in excess of 30 percent prior to May 10, 2019 and in excess of 50 percent thereafter for service-connected PTSD The Veteran service-connected PTSD is rated 30 percent disabling prior to May 10, 2019 and 50 percent disability thereafter under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. The DC uses the General Rating Formula for Mental Disorders, which provides for a 30 percent rating for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and/or mild memory loss (such as forgetting names, directions, or recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted for a mental disorder when there is total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation or own name. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited A November 2010 VA examination report shows the Veteran reported symptoms of insomnia, nightmares, night sweats, and problems with loud sounds. The severity of the symptoms was reported as mild. He reported symptoms were constant, continuous, and ongoing. The Veteran reported that symptoms affected total daily functioning which results in fair. Trouble sleeping was reported. No reports of violent behavior or suicide attempts were noted. The Veteran was not undergoing any mental health treatment or had been hospitalized for a psychiatric condition. The Veteran reported his relationships with his children and spouse were good. Post-separation from service, the Veteran worked at a lumber company and in farming. He reported his relationships with co-workers and supervisors were good. The Veteran reported that since onset of his mental condition, he tended to isolate from others. Major social functional changes were not reported. He reported that he did not miss any time from work due to the mental health condition. Mental status examination noted that the Veteran’s orientation was within normal limits; appearance and hygiene were appropriate; behavior was appropriate; good eye contact; mood and affect showed anxiety; mild anxiety was displaying during the exam; communication, speech, and concentration was within normal limits; panic attack were absent; no suspiciousness were present; delusions were not reported; no hallucinations were noted; and obsessive compulsive behavior was absent. The examiner noted that the Veteran’s thought processes were appropriate; judgement was not impaired; abstract thinking was normal; memory was within normal limits; suicidal ideation was absent; homicidal ideations were absent. The examiner noted that the Veteran occasionally has some interference in performing activities of daily living. The mental condition also was noted to only occasionally cause some difficulties when performing some of his daily chores. The best description of the claimant's current psychiatric impairment was assessed as mild or transient but caused occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress. A February 2013 VA PTSD examination report shows that the Veteran’s PTSD resulted in occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Veteran was noted to be married with children and reported being anxious. He reported having a good relationship with his spouse and four children. The Veteran reported that since separation from service, he has been working on his family farm, but had been cutting back on work hours lately. The examiner noted symptoms of anxiety, chronic sleep impairment, mild memory loss, inability to establish and maintain effective relationships. A June 2015 VA PTSD examination report shows that occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational task, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran was noted to be married to his wife for 45 years, has four adult children, and had good relationships with them. The Veteran reported that after separation from service he worked at a family farm for the past 45 years, he denied having problems at work relating to others or completing tasks. The Veteran reported experiencing avoidance, negative alterations in cognition and mood, and hyper-arousal symptoms. He denied depressed mood, suicidal ideations, and psychotic symptoms. The examiner reported symptoms of anxiety and chronic sleep impairment. The examiner observed that the Veteran arrived early for the examination and well dressed and groomed. His mood and affect were mildly dysthymic. He was oriented to person, place, time, and setting. Thought processes were linear, logical, and goal directed. Judgement was intact. He was noted to be pleasant and cooperative throughout the examination. A May 2019 VA PTSD disability benefits questionnaire (DBQ), shows that the psychiatric disability caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran reported that since separation from service, he had worked on a farm and in a lumber yard. The Veteran reported that he lived on a farm and still milked cows but he was retired. He did not pursue his education after separation from service. The Veteran reported experiencing nightmares, fear of snakes, dislike of small spaces, intrusive memories, dislike of crowds, hypervigilance, issues with loud noise, loss of interest in activities, and passive thoughts of harming himself or others. The symptoms were noted to have negatively impact relationships such as social withdrawal, with leaving family gatherings and stopped visiting with friends. No current evidence of mania, panic, lethality, or psychosis were noted. The examiner identified symptoms of depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The examiner noted that the Veteran was on time and well groomed. Speech was noted to be normal rate and tone and thoughts were goal directed. Mood was dysthymic as was his affect. No evidence of lethality, psychotic thinking or clouded sensorium. He was noted to be fully alert and oriented with fair insight and judgment. After a review of the evidence of record the Board finds that a rating in excess of 30 percent is not warranted prior to May 10, 2019. The evidence does not demonstrate occupational and social impairment with reduced reliability and productivity. Although the Veteran reported anxiety and sleeping difficulty during this period on appeal, the Veteran maintained good relationships with his spouse and adult children. He also reported no difficulty in the workplace with coworkers or supervisors. Additionally, the evidence of record demonstrates the Veteran had normal speech, intact memory, normal judgement, and normal thoughts. The Veteran did not report panic attacks of more than once per week or difficulty with complex commands. The evidence did show some avoidance behavior, but, on the whole, the Veteran's symptoms and effects do not more nearly approximate the 50 percent evaluation requirements. Furthermore, the Veteran has continuously denied delusions, hallucinations, and suicidal or homicidal ideations. Accordingly, the Board finds that a higher evaluation is not warranted. The Board finds that on and after May 10, 2019 a rating in excess of 50 percent is not warranted. Although there were deficiencies in mood, due to depression and anxiety, there was good judgment and no impairment of thinking. There was no impairment at work. The Veteran also reported good relationships with his spouse and adult children. Thus, there was not deficiencies in most areas. Additionally, symptoms identified during the appeal period include chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; and disturbances of motivation and mood. The Veteran also self-reported experiencing nightmares, fear of snakes, dislike of small spaces, intrusive memories, dislike of crowds, hypervigilance, issues with loud noise, loss of interest in activities, and passive thoughts of harming himself or others. The Veteran has been fully oriented throughout the appeal and the 2019 VA examiner noted the Veteran was able to conduct his personal hygiene and other activities of daily living. Throughout the appeal period, the Veteran had normal speech, and no obsessional rituals which interfere with routine activities. Additionally, there was not any depression or panic that interfered with his ability to function independently. The Veteran denied suicidal ideations, although he noted a passing thought. These thoughts are indicative of a 70 percent evaluation, but the Board finds that these passing thoughts, when balanced with the other consistently denied suicidal ideations, are not of similar severity, frequency, and duration to the effects of the symptoms to warrant a 70 percent evaluation. See Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114 (Fed. Cir. 2013). Thus, the preponderance of the evidence is against a finding that a 70 percent is warranted; and higher ratings are not warranted. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 2. Entitlement to service connection for a bilateral knee disorder 3. Entitlement to service connection for a bilateral foot disorder The Veteran has filed claims for entitlement to service connection for a bilateral knee disability diagnosed as osteoarthritis and a bilateral foot disability diagnosed as bilateral calcaneal spurs. A review of the Veteran’s service treatment records shows no reports of symptoms or diagnosis of disabilities affecting the knees or feet. A June 2015 VA treatment record noted osteoarthritis of the knee. A May 2016 VA treatment record noted that the Veteran was assessed with bilateral plantar calcaneal spurs based on x-rays. During the April 2018 Board hearing, the Veteran testified that regarding his knee pain, he did not seek treatment until 2006 and experienced no knee pain during active service, although he did report some knee pain when kneeling in rice paddies. He stated that symptoms began within a month and continued since that time. Regarding his foot condition, the Veteran testified that the foot problems he experienced, were more related to a now service-connected skin condition. VA treatment records from 2006, the Veteran denied musculoskeletal complaints and no joint pain. In an August 2013 VA treatment record, the Veteran reported left knee pain, that began one month prior. He stated that there was no trauma or injury. A September 2013 VA record noted n x-ray showed left knee degenerative changes. The Veteran reported persistent knee pain. VA treatment records from 2014, 2015, and 2016 noted knee osteoarthritis. In an April 2014 VA record, the Veteran stated he had left knee pain that comes and goes. In May 2016 VA records, the Veteran reported tingling and numbness in his feet. An x-ray showed bilateral plantar calcaneal spurs. In a March 2019 VA record, the Veteran reported knee pain of 40 years. A May 2019 VA knee examination report noted a diagnosis of osteoarthritis of the left knee in September 2013. The Veteran reported that he did not have any knee injury during active service or until the 1980s. The Veteran also denied any medical evaluation for his knees until 2006. Upon review of the claims file, the examiner opined that the Veteran’s bilateral knee disability, which was first diagnosed almost 45 years after service, and with no injury noted or reported by the Veteran occurring during active service, was less likely than not related to active service. A May 2019 VA foot examination report shows a diagnosis of bilateral plantar fasciitis and calcaneal spurs. The Veteran reported occasional pain that would just come and go, not related to activity. After a review of the claims file, the examiner opined that it was less likely than not that the foot condition was incurred or due to active service, noting that the Veteran’s service treatment records were absent for any foot injuries or complaints and there was no diagnosis until 45 years after separation. In an August 2019 VA record, the Veteran stated he connected his knee pain to his war injury. The Board finds that the evidence of record does not support a finding of service connection for a bilateral foot or knee disorder. First, the Veteran’s STRs are silent for any foot or knee complaints. Second, the Veteran stated that his knee pain began one month after service and continued since that time and that his foot pain onset during service. The Board find these statements competent but not credible based on demeanor at the hearing and the conflicting evidence in the file. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, consistency with other evidence), aff’d, 78 F.3d 604 (Fed. Cir. 1996). Notably, in 2006 VA records, the Veteran did not report any knee or foot complaints and when initially reported in 2013, stated that the knee pain was of one-month duration. Feet pain was not reported until 2016. Third, the most probative evidence of record demonstrates the disorders are not related to service. The opinions in the May 2019 VA examinations are probative, because they are based upon a review of the evidence in the claims file and provides an explanation that contains clear conclusions and supporting data. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (holding that factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Furthermore, the chronic conditions did not manifest to a compensable degree in service or within a presumptive period, and continuity of symptomatology is not established. 38 U.S.C. §§ 1101 (3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Here, the Board notes that the medial evidence shows that the Veteran was diagnosed with arthritis of the knees and feet many years after separation from service. While the Veteran believes that his bilateral knee and feet disabilities are related to an in-service injury, event, or disease, the Veteran in this case is not competent to provide a nexus opinion. The issue is medically complex, as it requires knowledge of the interaction between the body, anatomical relationship, and an interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examination of record. Therefore, the claims are denied. 4. Entitlement to service connection for sleep apnea as secondary to service-connected PTSD The Veteran asserts that sleep apnea was incurred in his active service. He contends, alternatively, that his service-connected PTSD caused his sleep apnea. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When aggravation of a Veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen, supra. To prevail on the issue of secondary service causation, generally, the record must show (1) medical evidence of a current disability, (2) a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). An October 2018 VA treatment record shows that the Veteran’s treating psychiatrist reported reviewing the Veteran’s medical records and was currently providing treatment for the Veteran. The psychiatrist noted that a review of the current medical literature indicated an association between psychiatric disorders and sleep apnea. The psychiatrist noted that there was a substantially higher rate of sleep apnea in combat Veteran’s with PTSD than in the general population. The examiner opined that it was as likely as not that the Veteran’s service-connected PTSD led to the diagnosis of sleep apnea. A May 2019 VA DBQ shows that the examiner noted that the Veteran was diagnosed with sleep apnea via sleep study in February 2014. The examiner noted that the Veteran’s spouse reported a history of snoring, however it was noted the snoring was not diagnostic of sleep apnea. The examiner noted that service treatment records contained no reports or diagnosis of sleep apnea and that it was 45 years after separation before occurrence of the condition, and thus no reasonable nexus existed with service. The Board finds that the preponderance of the evidence supports the Veteran’s claim for entitlement to service connection for sleep apnea secondary to service-connected PTSD. Here, the probative evidence of record consists of the VA psychiatrist opinion that it was at least as likely as not the sleep apnea was due to the Veteran’s PTSD. The VA psychiatric based this conclusion on a review of the medical records and medical literature and provided a supporting explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in determining probative value of a medical opinion is whether the examiner was informed of the relevant facts); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Although the May 2019 VA examination report provided a negative nexus opinion, it did not address secondary service connection. Accordingly, service connection for sleep apnea as secondary to PTSD is warranted. 5. Entitlement to TDIU VA will grant TDIU when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. TDIU is granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. 38 C.F.R. § 4.16(a). If there are two or more such 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). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment. 38 C.F.R. §§ 3.340, 3.341, 4.16. The central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the veteran’s background including his employment and educational history. 38 C.F.R. §§ 3.321(b), 4.16(b). The Board does not have the authority to assign an extraschedular TDIU rating in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). Rather, the issue must be referred to the Director of Compensation Service for such assessment in the first instance. Kuppamala v. McDonald, 27 Vet. App. 447, 457 (2015). Thereafter, the Board has jurisdiction to review the entirety of the Director’s decision denying or granting an extraschedular rating and is authorized to assign an extraschedular rating when appropriate. Kuppamala, 27 Vet. App. at 457. For VA purposes, the term unemployability is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91, 57 Fed. Reg. 2,317 (Jan. 21, 1992). Consideration may be given to the veteran’s education, special training, and previous work experience, but not to his or her age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose, 4 Vet. App. at 363. The ability to work sporadically or obtain marginal employment is not substantially gainful employment. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment, i.e., earned annual income that does not exceed the poverty threshold for one person, is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). The Veteran’s service-connected disabilities are PTSD rated at 50 percent disabling, right shoulder disability rated at 20 percent disabling, diabetes mellitus type II rated at 20 percent disabling, bilateral upper extremity peripheral neuropathy each rated at 20 percent disabling, tinnitus rated at 10 percent disabling, and right lower extremity peripheral neuropathy rated at 10 percent disabling. The Veteran’s combined rating is 90 percent. As such, the Veteran meets the schedular rating criteria for a TDIU. See 38 C.F.R. §§ 4.16 (a), 4.25, 4.26. A review of the competent evidence of record, which includes the Veteran’s VA treatment records, when taken in total, does not suggest that the Veteran is unable to obtain or maintain substantially gainful employment on account of his service-connected disabilities. The Veteran has reported that after separation from service, he did not pursue his education. The Veteran has had a work history of working in a lumber yard, and also working on a family farm. More recently, the Veteran reported that he had cut down on his hours at the farm but did not attribute this to any of his service-connected disability. The Board has reviewed all the VA and private examinations of record concerning the Veteran’s service-connected disabilities. In a June 2015 VA examination, the Veteran reported he worked at a family operated farm for 45 years and had no problems relating to others or completing tasks. The February 2016 VA examination noted sleep apnea does not affect the ability to work. A July 2016 VA examination noted that the diabetes mellitus did not impact his ability to work. A May 2019 VA examination noted the shoulder limited the Veteran in overhead pressing and lifting. A May 2019 VA examination noted PTSD caused difficulty with occupational relationships. An April 2017 VA examination noted diabetic peripheral neuropathy and found there was no effect on the ability to work. The Veteran is competent to report symptoms of his service-connected disabilities. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). Additionally, he is credible in his reports of symptoms and their effect on his activities. He is not however competent to identify a specific level of disability of his disabilities according to the appropriate Diagnostic Codes or to assess whether the symptoms together preclude employment. Ultimately, it is a rating determination as to whether the Veteran's multiple service-connected disabilities prevent him from obtaining or maintaining substantially gainful employment. See Floore v. Shinseki, 26 Vet. App. 376, 381 (2013) (emphasizing that "medical examiners are responsible for providing a 'full description of the effects of disability upon the person's ordinary activity,'" (quoting 38 C.F.R. § 4.10 (2013)) while the rating agency "is responsible for 'interpret[ing] reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of the disability present'" (quoting 38 C.F.R. § 4.2)) (modification in original). Here, the Board finds that the evidence of record does not support a finding that the Veteran is unemployable due to his service-connected disabilities. It appears that, except for the Veteran’s PTSD and shoulder, the disabilities do not affect his ability to work. Even the PTSD, as rated, only indicates difficulty in relationships, but the Veteran has denied that effect. The Veteran has not identified or submitted any other evidence demonstrating that his service-connected disabilities, individually or in concert, preclude him from securing and maintaining substantially gainful employment and entitle him to a TDIU. Entitlement to TDIU is thus not warranted. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dworkin, 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.