Citation Nr: 21011403 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 15-14 748 DATE: March 1, 2021 ORDER Entitlement to service connection for a left knee disability is granted. Entitlement to a disability rating in excess of 10 percent for a right knee disability is denied. Entitlement to a disability rating higher than 10 percent for traumatic brain injury (TBI) prior to October 5, 2016, is denied. Entitlement to a compensable disability rating for TBI from October 5, 2016 is denied. Entitlement to a 50 percent disability rating for posttraumatic stress disorder (PTSD) with major depressive disorder prior to July 23, 2009, is granted. Entitlement to a disability rating in excess of 70 for PTSD with major depressive disorder as of July 23, 2009 is denied. Entitlement to a total disability rating based on individual unemployability as a result of service-connected disabilities (TDIU) prior to January 24, 2017 is denied. Entitlement to special monthly compensation (SMC) after January 24, 2017 is denied. FINDINGS OF FACT 1. The weight of the evidence shows that the Veteran’s left knee disability had its onset in service. 2. The Veteran’s right knee disability has not resulted in a compensable limitation of flexion or extension and no disability other than painful limitation of motion has been demonstrated. 3. Prior to October 5, 2016, the Veteran’s TBI residuals consisted of mild cognitive impairment of problems with memory and concentration; other TBI residuals of headaches and tinnitus were assigned separate disability ratings. 4. As of October 5, 2016, the Veteran’s TBI residuals were shown to be headaches and tinnitus, which were assigned separate disability ratings. 5. Prior to July 23, 2009, the Veteran’s PTSD with major depressive disorder resulted in occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships 6. As of July 23, 2009, the Veteran’s PTSD with major depressive disorder has not been shown to result in total occupational and social impairment. 7. Prior to January 24, 2017, the Veteran’s service-connected disabilities did not produce a disability picture characterized by an inability to obtain and maintain substantially gainful employment. 8. Since January 24, 2017, the Veteran’s combined disabilities do not yield a schedular 100 percent combined rating in addition to a single disability rated as at least 60 percent disabling. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left knee disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a disability rating in excess of 10 percent for a right knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5260, 5261. 3. The criteria for a disability rating in excess of 10 percent for TBI residuals prior to October 5, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.14, Diagnostic Code 8045. 4. The criteria for a compensable disability rating for TBI residuals as of October 5, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.14, Diagnostic Code 8045. 5. The criteria for a 50 percent disability rating for PTSD with major depressive disorder prior to July 23, 2009 have 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. 6. The criteria for a disability rating in excess of 70 percent for PTSD with major depressive disorder as of July 23, 2009 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. 7. The criteria for entitlement to TDIU prior to January 24, 2017 were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.16. 8. The criteria for entitlement to SMC since January 24, 2017 have not been met. 38 U.S.C. §§ 1114 (s), 5101, 5103, 5107, 5121; 38 C.F.R. §§ 3.350, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty military service from November 2002 to April 2003 and from February 2005 to April 2006, including service in Iraq for which he earned the Combat Action Badge, as well as National Guard service thereafter. These claims were previously before the Board in November 2018 when the claim of service connection for a left knee disability was reopened and all of the claims were remanded for further development to include additional VA examinations and opinions. The Board has reviewed the examinations and opinions obtained on remand and finds that there was substantial compliance with the remand directions, that the examinations are adequate for adjudicative purposes, and that no further development is required. Entitlement to service connection for a left knee disability Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All three elements must be established by competent and credible evidence in order that service connection may be granted. When there is an approximate balance of positive and negative admissible evidence regarding any issue material to the determination of a matter, the evidence is said to be in equipoise. In such situations, VA is required to afford the Veteran the benefit of the doubt. 38 U.S.C. § 5107 (b). The Veteran is service connected for a disability of the right knee, which has been diagnosed a retropatellar pain syndrome and which results in painful motion in the right knee with a noncompensable loss of range of motion. It is his contention that the pain he reported in service with respect to his right knee, which led to the grant of service connection, was also present in service in the left knee. Specifically, he has asserted to multiple examiners and testified at hearing that he has always had pain in both knees beginning in service and continuing to the present time, but the left knee disability has simply not been acknowledged to date. (See CAPRI, 07/16/2020; CAPRI, 10/08/2019.) The record shows that the Veteran’s left knee disability is assigned the same diagnosis as his right knee – retropatellar pain syndrome – and that the vast majority of the medical evidence shows identical or nearly identical findings in the left knee to those recorded in the right knee. (See CAPRI, 10/08/2019; C&P Examination, 09/26/2013; VA Examination, 03/08/2011; Medical Treatment Record, 09/13/2010.) The March 2011 VA examination provided range of motion findings in both knees (0 degrees of extension and 125 degrees of flexion), described both knees as having conditions moderate in severity, and stated that the condition was due to overuse that began while on active duty and was therefore more likely than not due to service. (See VA Examination, 03/08/2011.) Both the September 2019 and the July 2020 VA examinations yielded the opinion that the Veteran’s left knee has not been aggravated as a result of his right knee disability, because there is no evidence of a limp or favoring the right knee which would result in additional strain on the left knee. (See CAPRI, 07/16/2020; CAPRI, 10/08/2019.) Treatment notes from the Veteran’s National Guard service after his separation from active duty service show complaints of pain in the knees, meaning both knees, and he received a profile for light duty based on the disabilities of both knees. (See STR, 06/20/2012.) Notably, at a VA examination in February 2008, the examiner diagnosed bilateral tenosynovitis in the knees and retropatellar pain syndrome in both knees. (See VA Examination, 02/07/2008.) The examiner noted that the Veteran had the same symptoms in each leg and that there was documentation of knee problems while in service. At the time of service separation in November 2006, the Veteran documented knee problems and knee pain as a reason he might seeks benefits; the document did not indicate if both knees were affected or only one. (See STR, 01/07/2008.) The Board has considered all of the evidence with specific attention to the documents discussed above. Considering this evidence and affording the Veteran the benefit of the doubt, the Board finds that service connection for left knee disability is warranted. 38 U.S.C. § 5107 (b). The consistency of the medical evidence shows that the Veteran’s left knee and right knee demonstrate the same or nearly the same objective level of disability, which supports the Veteran’s assertions that his symptoms have affected both knees since service. In addition, the medical opinions on the question of aggravation have shown that there is no evidence of sequential disability or of a shift in weight-bearing or gait which would indicate that the left knee disability was caused by the right knee disability. The Veteran’s National Guard records show a bilateral knee disability and his private medical records describe a bilateral knee disability that began in basic training, just as the Veteran has testified. For all of these reasons, the Board finds that the claim of service connection for left knee disability should be granted. Entitlement to a disability rating in excess of 10 percent for right knee disability The Veteran is currently assigned a 10 percent disability rating for his right knee disability of retropatellar pain syndrome, also diagnosed as tenosynovitis and/or degenerative arthritis. He seeks a higher disability rating. Knee disabilities are rated based on range of motion findings (Diagnostic Codes 5260 and 5261) or recurrent subluxation or instability (Diagnostic Code 5257) or specific disabilities such as impairment of the semilunar cartilage (Diagnostic Code 5258). Knee disabilities may also be rated based on radiographic evidence of arthritis or on a diagnosed disability which results in painful motion or limitation of motion less than that necessary for a compensable rating based on range of motion. In this instance, the Veteran’s 10 percent disability has been assigned based on a diagnosed disability with painful motion and minor limitation of motion, using Diagnostic Code 5003. The evidence does not show recurrent subluxation or instability, so Diagnostic Code 5257 need not be considered, to include the recent revision to the rating schedule effective February 7, 2021. Limitation of motion of the knee is rated under either Diagnostic Code 5260 (limitation of flexion) or Diagnostic Code 5261 (limitation of extension). Separate ratings may be assigned for limitation of flexion and extension. Under Diagnostic Code 5260, flexion limited to 45 degrees is 10 percent disabling, flexion limited to 30 degrees is 20 percent disabling, and flexion limited to 15 degrees is 30 percent disabling. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, extension limited to 10 degrees is 10 percent disabling, extension limited to 15 degrees is 20 percent disabling, extension limited to 20 degrees is 30 percent disabling, extension limited to 30 degrees is 40 percent disabling, and extension limited to 45 degrees is 50 percent disabling. 38 C.F.R. § 4.71a. Neither Diagnostic Code 5260 or 5261 was affected by the recent revisions to the rating schedule. The Veteran has been provided several VA examinations throughout the course of the appeal. At the February 2010 VA examination, the range of motion findings included extension to 0 degrees and flexion to 135 degrees. (See VA Examination, 02/09/2010.) The examiner noted the Veteran’s report of limited function such as walking limited to less than 1 mile, standing limited to less than 1 hour, and sitting with knees flexed limited to less than 90 minutes. At the March 2011 VA examination, the Veteran had extension to 0 degrees and flexion to 125 degrees with painful motion. (See VA Examination, 03/08/2011.) At the September 2013 VA examination, the Veteran had extension to 0 degrees and flexion to 140 degrees, or full range of motion in his right knee, with an estimated loss of 5 to 10 degrees of flexion during a pain flare-up. (See C&P Exam, 09/26/2013.) At the September 2019 VA examination, the Veteran had extension to 0 degrees and flexion to 125 degrees, which during a pain flare-up would be reduced to 120 degrees. (See CAPRI, 10/08/2019.) In light of the fact that the Veteran’s right knee range of motion has not, at any point during the appeals period, been sufficiently limited to warrant a compensable rating, i.e. extension to 10 degrees or flexion to 45 degrees, an increased disability rating under Diagnostic Codes 5260 or 5261 is not warranted. As such, the currently assigned 10 percent disability rating based on painful motion and limitation of motion which is not compensable under Diagnostic Code 5003 is appropriate and the claim for increased disability rating must be denied. 38 C.F.R. § 4.71a. The evidence does not show that the Veteran has any of the diagnosis which would trigger application of other rating codes, such as Diagnostic Codes 5256 (ankylosis), 5258 (dislocated semilunar cartilage), 5262 (impairment of tibia and fibula), and 5263 (genu recurvatum). The Board again acknowledges that the rating criteria for musculoskeletal disabilities, including knees, were revised on February 7, 2021. In this instance, however, the specific rating criteria and Diagnostic Codes relevant to the Veteran’s right knee disability were not affected by the changes and the revisions are therefore not applicable. 38 C.F.R. § 4.71a; 85 FR 76460, Nov. 30, 2020; 86 FR 8142, Feb. 4, 2021. Entitlement to a disability rating higher than 10 percent for TBI prior to October 5, 2016 Entitlement to a compensable disability rating for TBI from October 5, 2016 The Veteran sustained a TBI in Iraq that was rated as 10 percent disabling prior to October 5, 2016. He seeks a higher disability rating for that time period. The Board notes that the Veteran has been afforded a separate 30 percent disability rating for headaches secondary to TBI as of October 28, 2009. He also has a separate compensable disability rating for tinnitus. In addition, the Veteran’s separate disability rating for mental health disabilities includes some consideration of emotional/behavioral residuals of TBI, which cannot be separated from the rated disabilities. Residuals of TBI are evaluated under Diagnostic Code 8045, which provides that there are three main areas of dysfunction that may result from TBIs and have profound effects on functioning: cognitive, emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction. The rater is to evaluate subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled ‘Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.’ However, the rater should separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere’s disease, even if that diagnosis is based on subjective symptoms, rather than under the ‘Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified’ table. Where the Veteran has subjective symptoms that do not interfere with work, instrumental activities of daily living, or relationships, including occasional headaches or mild anxiety, this should be considered a level ‘0’ impairment. Where the Veteran has three or more subjective symptoms as a result of TBI that mildly interfere with work, instrumental activities of daily living, or relationships, including intermittent dizziness, daily mild headaches, tinnitus, insomnia, or hypersensitivity to light or sound, this should be rated as a level ‘1’ impairment. Where the Veteran has three or more subjective symptoms hat moderately interfere with work, instrumental activities of daily living, or relationships, such as marked fatigability, blurred or double vision, and headaches requiring rest periods most days, this should be considered a level ‘2’ impairment. 38 C.F.R. § 4.124a. Pyramiding, considering the same symptoms under two or more Diagnostic Codes, is prohibited. 38 C.F.R. § 4.14. The table contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled ‘total.’ However, not every facet contains every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than ‘total,’ since any level of impaired consciousness would be totally disabling. The rater is to assign a 100 percent evaluation if ‘total’ is the level of evaluation for one or more facets. If no facet is evaluated as ‘total,’ assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. Note (1) provides: There may be an overlap of manifestations of conditions evaluated under the table with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Note (3): ‘Instrumental activities of daily living’ refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one’s own medication and using a telephone. These activities are distinguished from ‘Activities of daily living,’ which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Note (4) provides: The terms ‘mild,’ ‘moderate,’ and ‘severe’ TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. At the February 2008 VA examination, the Veteran complained of short-term memory problems such as forgetting appointments, misplacing household items, and forgetting to turn off lights. (See VA Examination, 02/06/2008.) He also had difficulty with word finding, nightmares and flashbacks, intermittent tinnitus, and headaches. At the February 2010 VA examination, the Veteran described having one to two prostrating headaches per month as a result of his TBI. (See VA Examination, 02/09/2010.) After he had a headache, he experienced difficulty with his balance. In August 2010, the Veteran was afforded a VA examination where he reported prostrating headaches, mild memory loss, and tinnitus. (See VA Examination, 08/12/2010.) The examiner diagnosed mild TBI without disabling residuals, with no symptoms other than those listed and no functional impairment of the Veteran’s employability. At the September 2013 VA examination, the Veteran was noted to have undergone neuropsychological testing in 2008 showing mild difficulties with attention and speed of information processing. (See C&P Exam, 09/25/2013.) The examiner attributed these symptoms to a combination of TBI, PTSD, and ADHD. At the October 2016 VA examination, the Veteran reported that he had experienced difficulties with focusing after his TBI, although that had resolved to some extent. (See C&P Exam, 10/05/2016.) The Veteran reported continuing difficulty with attention and concentration. He also continued to experience severe recurrent headaches as a result of his TBI. The examiner listed the Veteran’s TBI residuals as headaches; other potential residuals were denied. The examiner noted that the Veteran continued to report cognitive difficulties, which the examiner found were more likely the result of his PTSD, mental health conditions, and ADHD, in light of the fact that TBI related cognitive difficulties would have resolved over time. At the September 2019 VA examination, the Veteran’s PTSD symptoms were discussed. (See C&P, 09/16/2019.) The examiner noted that the Veteran’s difficulty concentrating and irritability were most likely related to his PTSD rather than his TBI and were considered in the assigned disability rating. After considering all of the evidence of record, with specific attention to the documents discussed, the Board finds that the Veteran’s TBI residuals prior to October 5, 2016 were no more than mild and were largely encompassed in separate disability ratings. Specifically, the Veteran exhibited mild difficulties with attention and cognition, as well as issues with dizziness after a headache. These symptoms are consistent with a single facet of TBI and warrant no more than a 10 percent disability rating under Diagnostic Code 8045. The Board notes the opinion of the VA examination in October 2016 that these issues are more properly considered to be the result of his PTSD than his TBI, with the only real TBI residuals being his headache disabilities. Therefore, the assigned noncompensable (0 percent) disability rating after October 5, 2016 is deemed appropriate and the Board finds no basis for a higher disability rating. 38 C.F.R. § 4.14. Entitlement to a disability rating in excess of 10 percent for PTSD with major depression prior to July 23, 2009 and in excess of 70 percent thereafter The Veteran seeks a higher disability rating for his mental health disability of PTSD with major depression. The disability is current assigned staged ratings of 10 percent prior to July 23, 2009 and 70 percent thereafter. The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication, is assigned a 10 percent rating. 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, mild memory loss (such as forgetting names, directions, recent events), is assigned a 30 percent rating. 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; difficulty in establishing and maintaining effective work and social relationships, is assigned a 50 percent rating. 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 worklike setting); inability to establish and maintain effective relationships, is assigned a 70 percent rating. 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; memory loss for names of close relatives, own occupation, or own name, is assigned a 100 percent rating. 38 C.F.R. § 4.130. A private treatment note from January 2008 indicated that the Veteran was experiencing PTSD and social anxiety, along with feelings of helplessness and hyper startle response. (See Medical Treatment Record, 01/15/2008.) At the VA examination in February 2008, the Veteran complained of social anxiety; he did not like being out in public. (See VA Examination, 02/06/2008.) He was not comfortable in groups of people he did not know well and became anxious in public places. He was being treated for depression with medication and counselling, which seemed to be helping him maintain at a mild level of symptoms. He reported anxiety, depressed mood off and on, difficulty sleeping, irritability, and trouble with his memory. The examiner stated that the Veteran’s mental health disability did not seem to impact his social functioning. He was not currently working because he had felt burned out while working as a mechanic and he was having difficulty settling on a career field to pursue. In a concurrent examination in February 2008 for TBI symptoms, the Veteran provided additional details on his memory issues, noting that he forgot to turn off lights or replace lids, missed appointments, and misplaced items around the house. (See VA Examination, 02/06/2008.) He also reported poor concentration and difficulty finding words. He reported severe social anxiety and being withdrawn, spending most of his time at home. He was very irritable, had fits of anger over minor annoyances, and was experiencing nightmares and flashbacks. A statement from the Veteran’s private mental health provider dated in February 2010 noted treatment for PTSD and for marital problems. (See Medical Treatment Record, 02/23/2010.) The provider had been treating the Veteran since May 2009 and indicated that the Veteran’s symptoms had recently worsened, in part because of his marital problems. The provider described the Veteran as having chronic anxiety symptoms, such as intrusive thoughts and flashbacks, nightmares occurring 3 times per week, hypervigilance and hypersensitivity to noise, and being emotionally disengaged. The Veteran’s mood was one of mild to moderate depression, impacted by financial strain and relationship problems. The provider stated that the Veteran’s mental health problems were having a significant impact on his ability to function on daily tasks, regulate his mood, and maintain significant relationships. At the March 2011 VA examination, the examiner noted that the Veteran’s PTSD symptoms interfered with his social functioning because he was irritable and snapped and argued with his wife. (See VA Examination, 03/08/2011.) He did not want to go out and social because of his panic attacks. He had difficulty at work due to memory problems and difficulty concentrating and had quit his job because he felt he was not getting the respect he deserved. The examiner noted that the Veteran had difficulty getting along with other people and had problems with authority which would impact his ability to function in the workplace. At the September 2013 VA examination, the examiner noted that the Veteran had shown mild attention and memory impairment on neurological testing which were likely related to a combination of his PTSD, his mild traumatic brain injury, and his ADHD. (See C&P Exam, 09/25/2013.) The examiner indicated that the Veteran had occupational and social impairment with reduced reliability and productivity, most of which was due to his PTSD. His symptoms included anxiety, difficulty sleeping, disturbances of motivation and mood, and difficulty adapting to stressful circumstances. The Veteran’s wife submitted a statement in April 2015 regarding the symptoms of PTSD she had witnessed. (See Buddy/Lay Statement, 04/03/2015.) She noted that the Veteran felt like a failure after he was unable to finish his schooling and had become extremely depressed. He could not be left alone with his children any longer because he would become overwhelmed and walk away from them. He was also exhibiting angry outbursts and having flashbacks. A treatment note from May 2015 showed that the Veteran’s wife was reporting that he still had angry outbursts. (See CAPRI, 06/12/2015.) He would become overwhelmed and begin yelling and kicking or hitting things. She said he would often look past her when she tried to speak to him, seemingly unaware of her presence, and it would take up to an hour for him to calm down. The Veteran reported having flashbacks, hypervigilance, and difficulty in crowds. At the Board hearing in June 2018, the Veteran testified that his PTSD symptoms were interfering with his ability to maintain relationships at work and in his social life. (See Hearing Transcript, 06/13/2018.) He had been fired from a recent welding job because he was unable to complete projects and was missing things. He stated that his disability status made it difficult for him to find a job. At the September 2019 VA examination, the Veteran reported daily moderate to severe PTSD symptoms including nightmares and intrusive thoughts. (See CAPRI, 09/06/2019.) He reported that he was distant from and mistrustful of other people, had panic attacks a couple times a week, and had difficulty sleeping. He tended to be irritable and hypervigilant, with difficulty concentrating and consistent depressive symptoms. The examiner described the Veteran as having occupational and social impairment with deficiencies in most areas of functioning as a result of his PTSD which caused depression and panic attacks. After considering all of the evidence of record, with specific attention to the documents listed, the Board finds that the Veteran’s PTSD and major depressive disorder prior to July 23, 2009, was productive of occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships, and that a 50 percent disability rating should be assigned. The Board acknowledges that the impact of the Veteran’s PTSD on his work efficiency and productivity at that time is difficult to assess given that the Veteran was not consistently employed during this time period. However, the Veteran’s symptomology of social anxiety, difficulty sleeping, irritability, and feeling burned out at work, along with anger outbursts and discomfort in public, when taken together, most approximate the level of impairment contemplated by the 50 percent rating. Deficiencies in most areas, however, were not shown such as to warrant a higher-still 70 percent rating. For example, he did have friends and was still wife his wife despite some marital difficulties. As of July 23, 2009, the Veteran’s PTSD with major depressive disorder has been rated as 70 percent disabling based on impairments in most areas of functioning. After reviewing the evidence, the Board finds that the Veteran has not met the level of impairment necessary for a 100 percent disability rating. A 100 percent disability rating would require evidence of total occupational and social impairment, which has not been demonstrated. The Veteran was married and had been intermittently employed during this time period. The Veteran’s symptoms of difficulty maintaining social and occupational relationships, depression, angry outbursts, nightmares, and flashbacks, while significant, are not consistent with the level of disability necessary to warrant a 100 percent disability rating for total occupational and social impairment. Therefore, the claim for a higher disability rating after July 23, 2009 must be denied. 38 C.F.R. § 4.130. Entitlement to TDIU prior to January 24, 2017 The Veteran filed for TDIU in November 2009, asserting that he had become too frustrated and anxious to be able to focus on work and learn his job because of his PTSD and had difficulty keeping up with his workload. (See Veteran’s Application for Increase, 11/30/2009.) As of January 24, 2017, the Veteran’s combined disability rating was 100 percent. Total disability ratings for compensation may be assigned, when the disabled person is, in the judgment of the rating agency, 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, this disability shall be ratable at 60 percent or more, and that, 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). The Veteran’s service-connected disabilities prior to January 24, 2017 were: PTSD with major depressive disorder, rated as 10 percent disabling prior to July 23, 2009 and 70 percent thereafter; obstructive sleep apnea, rated as 50 percent disabling as of January 7, 2011; tension headaches due to TBI, rated as noncompensable prior to October 28, 2009 and 30 percent thereafter; right knee disability, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling; and, TBI residuals, rated as 10 percent prior to July 23, 2009, and as noncompensable thereafter. At the February 2010 VA examination, the Veteran reported that he was unemployed but not retired and had been for one to two years. (See VA Examination, 02/09/2010.) He described the reason for this as being unable to keep up with the workload and was unable to concentrate or focus on his work because of his PTSD. He also experienced one or two prostrating headaches per month. The VA examiner in August 2010 noted that the Veteran’s headaches were not prostrating and that there was no impact on the Veteran’s employability. (See VA Examination, 08/12/2010.) A statement by the Veteran’s private medical provider, received in September 2010, discussed the Veteran’s knee problems and stated that the Veteran would be able to work despite this condition, albeit in a sedentary job rather than manual labor. (See Medical Treatment Record, 09/13/2010.) In February 2013 the Social Security Administration considered the Veteran’s application for disability benefits and concluded that he was not disabled for their purposes. (See Medical Treatment Records, 02/25/2015.) The Veteran was noted to be functioning as a stay-at-home father and was interested in attending college courses or participating in vocational rehabilitation. At the VA examination in September 2013, the examiner noted that the Veteran had not worked since 2008 but functioned as the primary caregiver for his young children without any difficulty. (See C&P Exam, 09/25/2013.) The Veteran was attending college and was getting grades ranging from Bs to Ds in his classes, which he attended regularly. At the VA examination in October 2016, the examiner noted that the Veteran’s headache disability would impact his ability to work if he did not receive treatment for the pain because he would have to take time off work once or twice a week when the headaches were most severe. (See C&P Exam, 10/05/2016.) At the January 2017 VA examination, the Veteran described severe symptoms related to his irritable bowel syndrome (IBS), which interfered with his ability to function. (See C&P Exam, 01/24/2017.) He reported frequently having nine or ten bowel movements per day with urgency so great he had sometimes had to jump from his car in traffic to find a public restroom. The examiner noted that this would interfere with his ability to work in that he would need to be close to a restroom, although no specific activities would be precluded. After considering all of the evidence of record, with specific attention to all of the documents discussed throughout this decision, the Board finds that entitlement to TDIU prior to January 2017 was not demonstrated. Specifically, prior to the information on functional impairment related to IBS obtained at the VA examination, the Veteran’s disability picture did not preclude him from working, although it did limit his ability to work. The disability picture reflected mental health issues including irritability, difficulty dealing with people, and problems following directions, as well as difficulty standing for long periods and prostrating headaches once or twice per week. However, the evidence reflected that the Veteran was functioning as a full-time parent to his children and was trying to attend school or obtain other work. As such, the criteria for a total disability rating were not met prior to January 24, 2017, and the claim must be denied. 38 C.F.R. § 4.16. Entitlement to special monthly compensation (SMC) after January 24, 2017 The Board has considered the question of entitlement to special monthly compensation after January 24, 2017 under the standard of Bradley v. Peake, 22 Vet. App. 280 (2008). Bradley provides that the Board must consider a TDIU claim despite the existence of a schedular total rating if VA finds the separate disability supports a TDIU independent of the disability that is rated 100 percent. Id. at 294. In short, if the Veteran has a single disability rated as at least 60 percent disabling in addition to the disabilities necessary for a schedular 100 percent rating and that single disability renders the Veteran unemployable or permanently housebound, SMC would be warranted under 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350. In this instance, the Veteran has a single disability – PTSD – which is rated as 60 percent or greater, in addition to multiple additional disabilities. The remaining disabilities of obstructive sleep apnea (50 percent disabling), tension headaches (30 percent disabling), irritable bowel syndrome (30 percent disabling), allergic rhinitis (30 percent disabling), right knee disability (10 percent disabling), and tinnitus (10 percent disabling), when combined using the Combined Ratings Table at 38 C.F.R. § 4.25, yield a combined result of 87 percent. An 87 percent rating is rounded up to 90 percent under 38 C.F.R. § 4.25. Thus, the Veteran’s additional disabilities separate from his PTSD would not constitute a 100 percent schedular rating and the provisions of Bradley would not be triggered, such that entitlement to SMC after January 24, 2017 is not warranted. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Cheryl E. Handy 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.