Citation Nr: 21015265 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 14-27 366 DATE: March 17, 2021 ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for a left hip disorder is denied. Entitlement to service connection for a right ankle disorder is denied. Entitlement to service connection for a left knee disorder is denied. Entitlement to service connection for a right knee disorder is denied. Entitlement to service connection for obstructive sleep apnea is denied. Entitlement to an initial evaluation in excess of 20 percent for left shoulder disability is denied. Entitlement to an initial evaluation in excess of 20 percent for right shoulder disability is denied. Entitlement to initial rating of 30 percent for residual surgical scars, status post right and left shoulder arthroscopy prior to September 15, 2020 is granted. Entitlement to a rating in excess of 30 percent for residual surgical scars, status post right and left shoulder arthroscopy since September 15, 2020 is denied. Entitlement to a total disability rating due to individual unemployability (TDIU) is denied. REMANDED Entitlement to service connection for a breathing condition is remanded. FINDINGS OF FACT 1. The Veteran was diagnosed with hypertension in service, and hypertension was noted within the first year after his separation from active service. 2. Although the Veteran experiences recurrent left hip pain, the record reflects this impairment is already associated with his service-connected lumbar spine and right lower extremity radiculopathy disabilities. 3. The preponderance of the competent evidence is against a finding that the Veteran’s current right ankle disorder was incurred in service or is otherwise related to an in-service event, injury or disease, to include as secondary to service-connected disability. 4. The preponderance of the competent evidence is against a finding that the Veteran’s current left knee disorder was incurred in service or is otherwise related to an in-service event, injury or disease, to include as secondary to service-connected disability. 5. The preponderance of the competent evidence is against a finding that the Veteran’s current right knee disorder was incurred in service or is otherwise related to an in-service event, injury or disease, to include as secondary to service-connected disability. 6. The preponderance of the competent evidence is against a finding that the Veteran’s current obstructive sleep apnea was incurred in service or is otherwise related to an in-service event, injury or disease, to include as secondary to service-connected disability. 7. The Veteran’s left shoulder disability has been manifested by painful limitation of motion but has not more nearly approximated limitation of motion midway between the side and shoulder levels or to 25 degrees from side, ankylosis of scapulohumeral articulation, or impairment of the humerus, clavicle, or scapula. 8. The Veteran’s right shoulder disability has been manifested by painful limitation of motion but has not more nearly approximated limitation of motion midway between the side and shoulder levels or to 25 degrees from side, ankylosis of scapulohumeral articulation, or impairment of the humerus, clavicle, or scapula. 9. Resolving any reasonable doubt in the Veteran’s favor, the Veteran has five residual scars, status post left and right shoulder arthroscopies, that have been painful throughout the appeal period. 10. At no point during the pendency of the appeal has any of the Veteran’s residual scars, status post left and right shoulder arthroscopies, been unstable. 11. Prior to September 2020, the evidence demonstrates that the Veteran had been able to maintain substantially gainful employment, despite his service-connected disabilities. 12. The Veteran has been in receipt of a combined disability rating of 100 percent for his service-connected disabilities since September 13, 2013; he does have a single service-connected disability alone that renders him unable to secure and follow substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for entitlement to service connection for a left hip disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 3. The criteria for entitlement to service connection for a right ankle disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 4. The criteria for entitlement to service connection for a right knee disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 5. The criteria for entitlement to service connection for a left knee disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 6. The criteria for entitlement to service connection for obstructive sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 7. The criteria for entitlement to an initial evaluation in excess of 20 percent for left shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5201. 8. The criteria for entitlement to an initial evaluation in excess of 20 percent for right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5201. 9. The criteria for entitlement to initial rating of 30 percent prior to September 15, 2020 for residual surgical scars, status post right and left shoulder arthroscopies, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Codes 7804, 7805. 10. The criteria for entitlement to a rating in excess of 30 percent since September 15, 2020 for residual surgical scars, status post right and left shoulder arthroscopies, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Codes 7804, 7805. 11. The criteria for entitlement to a total disability rating due to individual unemployability (TDIU) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had qualifying service based on several periods of active duty, active duty for training (ACDUTRA), and inactive duty for training (INACDUTRA) between March 1992 and May 2012. In particular, DD Forms 214 signifying active duty or ACDUTRA for the following dates are of record: March to June 1992; May to August 2004; January 2009 to April 2010; and April 2011 to May 2012. The Board acknowledges that additional VA treatment records associated with the claims folder following the November 2020 supplemental statement of the case (SSOC). These records only continue to show the Veteran receives treatment for lumbar spine and mental health disability, and they are essentially cumulative in nature to the previous evidence of record. Accordingly, there is no prejudice to the Veteran for the Board to proceed with a decision on the merits of the Veteran’s claim without initial consideration, or without obtaining a waiver of this consideration. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The term “active military, naval or air service” is further defined as (1) active duty or a period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and (2) any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. See 38 U.S.C. § 101 (24). Service connection for disability arising from INACDUTRA is permitted only for injuries, not diseases, incurred or aggravated in the line of duty, (with the exceptions for acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident, not pertinent here). See Brooks v. Brown, 5 Vet. App. 484, 485 (1993). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Hypertension is a chronic disease under 38 C.F.R. § 3.309 (a), but patellofemoral pain syndrome ligament sprain, and sleep apnea are not. Where a chronic disease under 3.309(a) is “shown as such in service” (“meaning clearly diagnosed beyond legitimate question,” Walker, 708 F.3d at 1339 ), or in the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). Additionally, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury; or, for any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of nonservice-connected condition. 38 C.F.R. § 3.310 (a)-(b). 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for hypertension The Veteran reports that he developed high blood pressure during service, and he has been intermittently treated with high blood pressure medication. He contends that his hypertension had an onset during, and he continues to have a current disability since service. For VA purposes, hypertension means that the diastolic pressure is predominantly 90 or greater, and isolated systolic hypertension means that the systolic pressure is predominantly 160 or greater with a diastolic pressure of less than 90. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran’s service treatment records show he had intermittently higher and then lower blood pressure readings from 2009 to 2012, and that he was diagnosed with hypertension in December 2011 during a cardiac evaluation. In addition, a March 2012 service treatment records reflects the Veteran’s medical history included a diagnosis of hypertension treated with medication. Medical records within the first post-service year include May 2013 and July 2013 VA treatment records which note a diagnosis of hypertension. The Board acknowledges that the medical records reflect that the Veteran’s high blood pressure medication was discontinued in July 2013, and another high blood pressure medication was not started until October 2018. In addition, in a May 2018 VA hypertension examination, the VA examiner concluded that there was insufficient evidence for a diagnosis of hypertension at that time, and his past intermittent hypertension had resolved with no residuals. However, intermittent VA treatment records continued to show a medical history of hypertension as well as elevated blood pressure readings. See August 2013, September 2014, February 2015, September 2015, October 2015, and October 2017 VA treatment records. While chronic hypertension may not be clearly shown throughout the pendency of appeal, elevated blood pressure was repeatedly shown, and which subsequently required restart of high blood pressure medication. Moreover, a review of the evidence demonstrates that the Veteran had a diagnosis of hypertension, which required medication during service as well as within the first year after his separation from service. With application of the benefit-of-the-doubt rule, 38 U.S.C. § 5107 (b), the Board finds such was the case, and service connection for hypertension is warranted. 2. Entitlement to service connection for a left hip disorder The Veteran asserts that he has a current left hip disorder that was incurred during his period of service. In the alternative, he asserts that he has a left hip disorder that is secondary to service-connected back disability. The Board acknowledges that the Veteran has reported recurrent left hip pain throughout the pendency of this case. However, the competent medical evidence is against a finding that the Veteran has a current diagnosed left hip disability. The Board is cognizant of the fact the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that where pain causes functional impairment, a disability for VA compensation purposes exists, even if there is no underlying diagnosis. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Nevertheless, in this case, the Veteran’s complaints of left hip pain have been attributed to and associated with his already service-connected lumbar spine and left lower extremity radiculopathy disabilities. In pertinent part, various medical and lay evidence of record reflects complaints of left hip pain associated with his treatment for lumbar spine disability. In a May 2018 VA examination report, the Veteran described his bilateral hip pain as involving his entire lateral pelvis and “all the way around hurts.” He denied any specific hip injury but stated that he had been informed by medical providers that his hip pain might be due to his lumbar spine disability. He described increased hip pain with prolonged sitting and flare-ups of his lumbar spine disability. Based on the findings from clinical evaluation, the May 2018 VA examiner concluded that the Veteran did not have a current left hip diagnosis and his hip symptomatology was consistent with his lumbar spine disability. The VA examiner noted that the Veteran’s hip pain that was reproduced with palpation of the psoas musculature. Soreness and tightness in this muscle is common with lumbar spine disability. While the Veteran has pain with forced internal rotation of hips, this does not clearly reproduce his hip pain. There was no x-ray evidence of arthritis in the left hip, and the Veteran’s description of hip pain is not typical in a diagnosis of hip arthritis. The VA examiner’s medical opinion goes to the effect that the Veteran’s current left hip pain is due to his lumbar spine disability as opposed to be a separate and distinct hip disability. The Board notes the May 2018 VA examiner was familiar with the Veteran’s medical history, and accurately summarized pertinent findings regarding the left hip in the examination report. In addition, this opinion was not expressed in speculative or equivocal language and was supported by stated rationale that was consistent with the medical history and examination findings. Accordingly, the Board finds this opinion is entitled to significant probative value in the instant case. In view of the foregoing, the Bord finds that the Veteran’s recurrent left hip pain is not reflective of a separate and distinct left hip disability for which service connection may be established as these complaints are already associated with service-connected disabilities. Therefore, to establish service connection for a left hip disorder based upon such complaints would be a violation of the prohibition against pyramiding. See 38 C.F.R. § 4.14. Consequently, the Board concludes the preponderance of the evidence is against the claim, and it must be denied. 3. Entitlement to service connection for a right ankle disorder 4. Entitlement to service connection for a right knee disorder 5. Entitlement to service connection for a left knee disorder The Veteran asserts that his current bilateral knee and right ankle disorders were incurred during his period of service. He reports that his bilateral knee problems are as a result of his physical training, to include running, and he suffered multiple ankle twisting injuries during service. In the alternative, he asserts that his bilateral knee and right ankle disorders that are secondary to service-connected lumbar spine disability. He reports that overcompensation for his lumbar spine disability due to shifting weight has caused his current bilateral knee and right ankle problems. See September 2013 statement in support of the case. Turning first to the issue of direct service connection, the Board concludes that, while the Veteran has current diagnoses of patellofemoral pain syndrome for each knee and chronic lateral collateral ligament sprain in the right ankle, and he has provide lay evidence of the onset of knee and ankle pain during service, the preponderance of the evidence weighs against finding that the Veteran’s current bilateral knee and right ankle disorders began during service or is otherwise related to an in-service injury, event, or disease. The Veteran has provided lay statements that he experienced bilateral knee pain during his period of service from running as well as performing his duties while lifting patients, and he suffered multiple ankle twisting injuries. See September 2013 statement in support of the case, as well as May 2018 VA examination reports. However, the Veteran’s service treatment records do not show complaints or treatment for any knee or right ankle problems during his period of service. The first post-service evidence of chronic bilateral knee and right ankle problems comes when he initiated his claims for service connection for bilateral knee and bilateral ankle disorders in September 2013. VA treatment records show that Veteran complained of bilateral knee and bilateral ankle pain in August 2015; however, x-rays of the knees and ankles were negative for abnormalities. The Veteran was diagnosed with bilateral patellofemoral pain syndrome and chronic right ankle lateral collateral ligament sprain based on clinical evaluation during the May 2018 VA examinations. The record does not demonstrate evidence of a chronic bilateral knee disorder and right chronic right ankle lateral collateral ligament sprain until years after his separation from service. While the Veteran is competent to report having experienced symptoms of knee and ankle pain since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of patellofemoral pain syndrome and chronic ankle lateral collateral ligament sprain. The issues are medically complex, as they require knowledge of musculoskeletal symptom and interpretation of complicated clinical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, in the May 2018 VA medical opinion reports, the VA examiner opined that the Veteran’s current bilateral knee and right ankle disorders are less likely than not related to an in-service injury, event, or disease, including in-service complaints of pain. The rationale was there was no significant documentation of knee or right ankle problems during the Veteran’s military service. The Veteran’s August 2015 x-rays were normal. The Board acknowledges that the examiner’s opinion is partially based on a lack of contemporaneous records. However, this VA opinion coupled with the medical evidence as a whole is probative, and therefore the Board finds that the VA examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As to the Veteran’s assertion for secondary service connection, the Board finds that the preponderance of evidence weighs against a finding of a nexus between the Veteran’s current bilateral knee and right ankle disorders and his service-connected lumbar spine disability. In the May 2018 VA medical opinion report, the VA examiner concluded that it was less likely than not that the Veteran’s bilateral knee and right ankle disorders were proximately due to or aggravated by his service-connected lumbar spine disability. The rational in support of this medical conclusion was that the knees and ankles are below the lumbar spine in the kinetic chain and altered forces at the lumbar spine do not impact the knees. This is evidence against a finding that the lumbar spine disability caused or aggravated his current bilateral knee and right ankle disorders. The extent that the Veteran asserted that his bilateral knee and right ankle disorders are secondary to his service-connected PTSD disability, the May 2018 VA examiner concluded that his bilateral knee and right ankle disorders were not proximately due to or aggravated by his PTSD disability, as they are due to biomechanical forces and not psychological forces. There is no competent medical opinion in support of the Veteran’s claims on either direct or secondary basis. While the Veteran believes that his bilateral knee and right ankle disorders are related to an in-service injury, event, or disease, or secondary to his lumbar spine disability, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, and it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. See Jandreau, 492 F.3d at 1377 n.4; see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight in the May 2018 VA examiner’s opinions. In conclusion, the Board finds that the preponderance of the evidence does not support that the Veteran’s current bilateral knee and right ankle disorders had an onset during active service or that they are otherwise related to his service, to include as secondary to his service-connected lumbar spine and PTSD disabilities. As the preponderance of evidence weighs against the Veteran’s claims, there is no reasonable doubt to be resolved, and the claims must be denied. 6. Entitlement to service connection for obstructive sleep apnea The Veteran seeks entitlement to service connection for obstructive sleep apnea. He reports that he has a history of snoring and witnessed apneas during his period of service. In the alternative, the Veteran asserts his obstructive sleep apnea is secondary to his service-connected PTSD disability. See August 2014 notice of disagreement, February 2016 statement in support of the case, and February 2016 informal hearing presentation. There is no dispute in this case that the Veteran has a current disability. The evidence of record shows the Veteran was first diagnosed with obstructive sleep apnea in April 2018. See April 2018 Sleep Study; May 2018 VA sleep apnea examination. (The Veteran’s symptom of sleep disturbances is already being compensated as symptom associated with his service-connected PTSD disability.) To the extent that the Veteran has alleged that his sleep apnea is directly related to service, the Board finds that there is no evidence linking his sleep apnea to his military service. Although the Veteran reported a history of sleep problems since 2004, including snoring and witnessed sleep apneas, service treatment records are negative for any documentation of complaint, relevant findings, treatment for, or diagnosis of sleep apnea. VA treatment records reflects that a May 2015 VA sleep study had been negative for sleep apnea, and the Veteran was not diagnosed with sleep apnea until an April 2018 VA sleep study. Moreover, in a May 2018 VA medical opinion report, the VA examiner concluded that it is less likely than not that the Veteran’s obstructive sleep apnea was caused by service or otherwise related to his service. The rationale was that there was no indication in the Veteran’s service treatment records of a diagnosis of sleep apnea nor symptoms suggestive of sleep apnea. While the Veteran reported snoring, witnessed apnea, and fatigue during service, the VA examiner noted that such reported symptoms did not make a medical diagnosis of obstructive sleep apnea. The VA examiner noted that the presence of snoring often occurs without sleep apnea and medical studies show that while complaints of snoring are common in patients with sleep apnea, there is no predictive value for diagnosing sleep apnea based on snoring. In addition, occasional apnea during sleep can occur up to 5 times an hour in individuals who do not have sleep apnea. There are many causes for sleep difficulties other than sleep apnea, such as the Veteran’s well-documented sleep difficulties related to his service-connected PTSD disability. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no contrary opinion of record. As indicated earlier in this decision, the Veteran also contends that his sleep apnea was caused or aggravated by his PTSD disability. The Veteran has current diagnosis of sleep apnea and he alleges his PTSD disability caused his sleep apnea, and therefore, the remaining question involves whether there is a medial nexus between the two. The Board finds that the preponderance of evidence is against such a medical nexus. In the May 2018 VA medical opinion report, the VA examiner concluded that it was less likely than not that the Veteran’s obstructive sleep apnea was proximately due to or aggravated by his service-connected PTSD, back, joint, and/or gastrointestinal disabilities. The supporting rationale was that obstructive sleep apnea is due to an anatomical or physical obstruction to the free flow of air through the passages of the back of the nose, throat, and pharynx. The most important risk factors for the development of obstructive sleep apnea include age, male gender, upper airway soft tissue abnormalities, nasal congestion, and obesity. VA examiner found that a review of the medical literature does not support the contention that the Veteran’s PTSD disability caused or aggravated his obstructive sleep apnea. While there is some evidence of an association between sleep apnea and PTSD, such as increased prevalence of sleep apnea in individuals with PTSD, such evidence is not sufficient to determine causation or permanent aggravation. Further, the VA examiner noted that there is some evidence of an association between sleep apnea and gastroesophageal reflux disorder (GERD); however, an increased association is not sufficient to determine causation or permanent aggravation. There is no peer reviewed medical literature that documents that GERD or other gastrointestinal disorders, such as irritable bowel syndrome, cause or aggravate sleep apnea. Moreover, the VA examiner found no medical evidence of permanent aggravation of the Veteran’s obstructive sleep apnea by his PTSD, back, GERD, and joint disabilities. Further, the May 2018 VA examiner concluded that it is less likely than not that a medication used to treat the Veteran’s service-connected disability has caused or permanently aggravated the Veteran’s obstructive sleep apnea. The VA examiner noted that a review of the medical literature does not show that the Veteran’s medications used to treat his PTSD and GERD disabilities include sleep apnea as an adverse side-effect. The Veteran did not take narcotics or NSAIDs. In addition, if the Veteran were to take any medications in the future for a service-connected condition which aggravated his sleep apnea, the aggravation would only be temporary because the aggravation would stop immediately after discontinuation, thus not causing permanent aggravation. The VA examiner noted that there are nonsedating medications which are available to treat the Veteran’s service-connected mental health condition. Finally, VA examiner acknowledged that Veteran gained weight up to 250 pounds between 2015 and 2016 while being treated for antidepressant drugs for his PTSD disability; however, he had lost all the excess weight prior to his April 2018 sleep study. The Board finds that the VA examiner’s medical opinions regarding the etiology of the Veteran’s obstructive sleep apnea to be highly probative evidence against the Veteran’s claim for service connection on a secondary basis. The Board finds the VA examiner’s opinion to be thorough and well-reasoned, with reference to competent medical literature. At present, the competent medical evidence of record does not contain a contrary medical opinion indicating that the Veteran’s sleep apnea was caused or aggravated by a service-connected disability. The Board acknowledges the Veteran’s contention that his sleep apnea is related to PTSD, and that he has referenced medical literature in support of his contentions. See August 2014 notice of disagreement, and February 2016 informal hearing presentation. These contentions were considered and addressed by the VA examiner in the rationale statement, which weighs heavily against the Veteran’s claim. Moreover, the record does not reflect that the Veteran possesses the requisite expertise to provide any medical diagnosis or opinion on etiology, and his lay opinions on this matter, insofar as they are intended as such, cannot be considered competent evidence in support of his claim. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (affirming that lay evidence is generally not competent to establish medical diagnosis or etiology). The Board finds that the Veteran’s claim for service connection for obstructive sleep apnea, to include as secondary to a service-connected disability, is not warranted. The preponderance of the evidence weighs against the claim, and the benefit of the doubt rule is inapplicable. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 3.303; Gilbert, 1 Vet. App. at 53. Increased Rating 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. 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. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. 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). When 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. 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). 7. Entitlement to an initial evaluation in excess of 20 percent for left shoulder disability 8. Entitlement to an initial evaluation in excess of 20 percent for right shoulder disability The Veteran contends that he is entitled to ratings for his bilateral shoulder disabilities because he is unable to lift his arms to shoulder height or perform overhead work without severe pain. See October 2013 notice of disagreement. He also reports that he has activity restrictions due to functional impairment associated with his bilateral shoulder disabilities. See January 2015 VA Form 28-1902b, Counseling Record-Narrative Report. The Veteran’s right and left shoulder disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of the arm. Under Diagnostic Code 5201, 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 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, Diagnostic Code 5201. Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). Effective February 7, 2021, the VA regulations for Musculoskeletal System and Muscle Injuries were amended, and it included specific changes to Diagnostic Code 5201. 85 Federal Register, 76453, 76462 (November 30, 2020) (codified at 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of arm). The changes to Diagnostic Code 5201 provided clarification limitation of motion of the arm includes either flexion or abduction, and it also now provided that shoulder level is 90 degrees and midway is 45 degrees. Id. When a law or regulation changes during the pendency of an appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (May 23, 2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (May 23, 2000); Kuzma, 341 F.3d 1327. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). The Board finds that the preponderance of the evidence is against ratings in excess of 20 percent for right and left shoulder disabilities. The evidence of record shows that the Veteran is right-handed. See January 2013 VA examination report. The Board acknowledges the Veteran’s lay reports of stiffness, weakness, and pain in his shoulders, and that he had functional loss due to inability to lift his arms above his shoulder and perform overhead due to bilateral shoulder pain. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he is unable to lift his arms above shoulder height due to severe pain would not result in symptoms more nearly approximating limitation of motion of the arm midway between side and shoulder level of the major extremity or limitation of motion of the arm to 25 degrees from the side of the major or minor extremity. A review of the medical evidence, to include VA treatment records and examinations, reveals that the Veteran’s right and left shoulder disabilities do not rise to the level of severity for which to warrant higher ratings, under the appropriate Diagnostic Code for limitation of motion for the shoulder. In this regard, VA medical records demonstrate that the Veteran’s left and right shoulders at worst have flexion limited to 90 and 100 degrees, respectively, due to pain. See June 2013 VA physical therapy treatment note; and January 2013 and May 2018 VA shoulder examination reports. Notably, during the May 2018 VA shoulder examination, the Veteran specifically denied flare-ups in either shoulder, but he reported that he avoids using either arm above 90 degrees due to shoulder pain. As the objective evidence of record shows that the Veteran’s right and left shoulder disabilities are limited at most to approximately shoulder level, even considering repeat motion and pain, the Board must find that the preponderance of the evidence is against a finding that the Veteran is entitled to a higher rating for either shoulder disability under old or new rating criteria for limitation of motion of the arm. The Board finds that the reported symptoms and manifestations of the Veteran’s bilateral shoulder disabilities have been adequately considered in the currently assigned 20 percent rating each, as the rating schedule specifically contemplates factors such as weakened movement, less movement than normal, and interference with weight bearing. 38 C.F.R. §§ 4.45, 4.59. The evidence does not reflect functional impairment congruent with a higher rating for either shoulder. At no point during the appeal period does the record reflect that the Veteran’s bilateral shoulder disability is manifested by flexion or abduction has been limited midway between side and shoulder level (to 45 degrees) or less, even due to repeated use overtime or during flare-ups. Thus, the Board finds that the currently assigned 20 percent ratings are appropriate, even after considering functional limitations and flare-ups. DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. In this regard, VA and private medical records during the pendency of the appeal do not demonstrate ankyloses of either shoulder, or any impairment of the clavicle, or scapula; the humerus is separately rated, and not on appeal herein. The Veteran has not reported any episodes of dislocation or subluxation, and physical examinations conducted both by VA examiners of record reflects no such findings. Accordingly, Diagnostic Codes 5200 (ankyloses of) and 5203 (clavicle or scapula, impairment of) pertaining to the shoulder are not for application. As a final matter, the Board acknowledges the Veteran’s assertions that he should be assigned temporary total, 100 percent, disability ratings for convalescence following his left and right shoulder surgeries. See December 2014 informal hearing presentation. The record shows that the Veteran underwent right shoulder surgery on April 29, 2011 and left shoulder surgery on January 13, 2012, and both of these surgeries occurred during a period of the Veteran’s active duty and prior to award of VA compensation for bilateral shoulder disabilities. Accordingly, 38 C.F.R. § 4.30 for a temporary total disability rating for convalescence following surgery for either shoulder is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s appeal for rating in excess of 20 percent for either right or left shoulder disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 9. Entitlement to initial compensable rating prior to August 20, 2020 for residual surgical scars, status post right and left shoulder arthroscopies 10. Entitlement to increased rating in excess of 20 percent from August 20, 2020 to September 14, 2020, and in excess of 30 percent since September 15, 2020 for residual surgical scars, status post right and left shoulder arthroscopies The Veteran’s disability due to residual surgical scars, status post right and left shoulder arthroscopies, is rated as noncompensable under Diagnostic 7805, which allows for scars to be rated under disabling effects. See 38 C.F.R. § 4.118. As of August 20, 2020, the Veteran was awarded a separate 20 percent for residual painful surgical scars, status post right and left shoulder arthroscopy, which was increased to 30 percent effective from September 15, 2020, under Diagnostic Code 7804, for painful scar(s). See Id. Given that nature of the Veteran’s disability due to residual surgical scars, as described below, the Board finds it more appropriate to evaluation as a single (and not separate) disability rating under Diagnostic Code 7804, for painful scar. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). However, the Board will still consider all possibly applicable diagnostic codes for scars. Diagnostic Code 7805 instructs to evaluate scars under Diagnostic Codes 7800, 7801, 7802, and 7804. During the pendency of the appeal, VA amended the criteria for rating the skin. See 83 Fed. Reg. 32,592 (July 13, 2018); 83 Fed. Reg. 38,663 (Aug. 7, 2018). The amendments were made effective as of August 13, 2018, and apply to claims, such as the Veteran’s, that were pending before VA as of that date, with the provision that the more favorable of the old and new criteria are to be applied. In this case, the changes to the relevant Diagnostic Codes pertain only to the title of the scar codes and the notes following the codes. The amendments to Diagnostic Codes 7800 through 7805 do not affect the analysis in the current case. Diagnostic Code 7801 sets forth the criteria for rating scars, other than of the head, face or neck, that are deep and nonlinear. Under this code, a 10 percent rating is warranted for scars that affect an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). Higher percentages are warranted for larger affected areas. Scars not of the head, face, or neck, that are superficial and nonlinear are rated under 38 C.F.R. § 4.118, Diagnostic Code 7802, which provides that a 10 percent rating is warranted for affected area(s) measuring 144 square inches (929 sq. cm.) or greater. A superficial scar is one not associated with underlying soft tissue damage. Id. at Note (1). Unstable or painful scars are rated under 38 C.F.R. § 4.118, Diagnostic Code 7804, which provides the following: a 10 percent rating is warranted for one or two scars that are unstable or painful; a 20 percent rating is warranted for three or four scars that are unstable or painful; and a 30 percent rating is warranted for five or more scars hat are unstable or painful. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. at Note (1). If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Id. at Note (2). Initially, the Board notes that there is conflicting evidence regarding the total number of scars associated with the Veteran’s disability due to residual surgical scars, status post left and right arthroscopies. In this regard, the Veteran has asserted that his residual scars disability is manifested by six residual surgical scars, with three scars on each shoulder. See November 2013 notice of disagreement. However, an August 20, 2020 VA scar examination report only reflects findings of a total of three residual scars involving the shoulders, and a September 15, 2020 VA scar examination report reflects findings of a total of five residual scars involving the shoulders. Pertinently, the April 2011 operation medical report for right shoulder arthroscopy surgery indicates three surgical entries and the January 2012 operation medical report for left shoulder arthroscopy surgery indicates two surgical entries. Follow-up treatment records noted that his surgical incisions following each surgery were considered well-healed, but do not indicate the number of surgical incisions. See May 2011 and January 2012 orthopedic and hand surgery treatment records. In consideration of the Veteran’s lay statement, and given the findings from April 2011 and January 2012 operation medical reports are more consistent with those reflected in the September 2020 VA examination, the Board finds that the preponderance of the evidence demonstrates that the Veteran’s disability due to residual scars, status post left and right shoulder arthroscopies, has been manifested by a total of five residual scars throughout the period under appeal. Moreover, the preponderance of competent evidence of record demonstrates that the Veteran’s residual surgical scars have been painful throughout the period under appeal. The Board has considered that in a January 2013 VA shoulder examination report, VA examiner found that the Veteran did not have painful or unstable scars related to residuals of bilateral shoulder surgery. However, a June 2013 VA physical therapy treatment record notes that the Veteran’s residual scars are keloid and may have complicated his recovery. In addition, in his November 2013 notice of disagreement, the Veteran contends that all of his residual shoulder scars are tender and painful. Moreover, during the August 2020 VA scar examination, the Veteran reported that he has frequent pain and itching over the listed scars, and his scars have become more painful with overuse of the shoulders. Finally, the September 2020 VA examiner observed that each of the Veteran’s five residual shoulder scars was considered painful and tender to palpation. Although the January 2013 VA examiner reported that the Veteran did not have any painful scars on his shoulders, the Veteran has competently and credibly stated that each of his residual shoulder scar has been painful during the entire period on appeal. The Veteran is competent to report pain and tenderness of the scars as they constitute observable conditions. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board cannot conclude that the evidence fails to show that the Veteran has at least five tender and painful scars under the provisions of 38 C.F.R. § 4.118, Diagnostic Code 7804 throughout the pendency of the appeal. Therefore, resolving any reasonable doubt in the Veteran’s favor, the Board finds that a 30 percent rating for residual surgical scars under Diagnostic Code 7805 is warranted for the entire period on appeal. 38 C.F.R. § 4.118, Diagnostic Code 7805. At no point during the pendency of the appeal is a rating in excess of 30 percent for residual shoulder scars is warranted under Diagnostic Code 7804, as none of the Veteran’s scars are both painful and unstable. See August 2020 and September 2020 VA scar examination reports. Further, the evidence shows that the Veteran’s residual scars are not of the head, face, or neck, are not deep and nonlinear, and is not associated with underlying soft tissue damage. Although they are superficial and not associated with underlying soft tissue damage, neither scar covers an area or areas of 144 square inches or greater. Therefore, separate ratings under Diagnostic Codes 7800, 7801, and 7802, are inapplicable. In conclusion, the Board finds that an initial 30 percent rating for residual surgical scars, status post left and right shoulder arthroscopies, prior to September 15, 2020 is warranted. The preponderance of the evidence is against the Veteran’s claim for a rating in excess of 30 percent for residual scars at any point during the period under appeal. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 11. Entitlement to a total disability rating due to individual unemployability (TDIU) The Veteran’s claim for entitlement to a TDIU was considered raised by the record and considered part of his claims for increased ratings in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). See September 2016 Board decision and remand. VA will grant TDIU when the evidence shows that a veteran is precluded by reason of a service-connected disability or disabilities from obtaining and maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. § §§ 3.340, 3.341, 4.16. Advancing age, any impairment caused by conditions that are not service connected, and prior unemployability status must be disregarded when determining whether a veteran is currently unemployable. 38 C.F.R. § §§ 4.16(a), 4.19. A total disability rating may be assigned when the schedular rating is less than total, where, if there is only one disability, the disability is rated at 60 percent or more, or where, if there are two or more disabilities, at least one disability is rated 40 percent or more and there is sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § § 4.16 (a). Disabilities of one or both upper extremities, or one or both lower extremities, including the bilateral factor, disabilities resulting from a common etiology or a single accident, and disabilities affecting a single body system, will be considered as one disability for TDIU purposes. 38 C.F.R. § 4.16 (a). The Veteran’s claim for a TDIU rating arises from his original service connection claims which were filed in June 2012. Since June 1, 2012, the Veteran’s service-connected disabilities include gastroesophageal reflux disorder (GERD) with irritable bowel syndrome (IBS), rated as 30 percent disabling; residual surgical scars, rated as 30 percent disabling; right shoulder disability, rated as 20 percent disabling; left shoulder disability, rated as 20 percent disabling; lumbar spine disability, rated as 20 percent disabling; left lower extremity radiculopathy, rated as 10 percent disabling; and right lower extremity radiculopathy, rated as 10 percent disabling. Pertinently, the Veteran’s bilateral shoulder disabilities can be combined to constitute one disability for purpose of a single 40 percent rating, and the Veteran has an overall combined rating of 80 percent. As of September 13, 2013, additional service-connected disabilities include posttraumatic stress disorder (PTSD) disability, rated as 70 percent disabling; right carpal tunnel syndrome, rated as 20 percent disabling; left carpal tunnel syndrome, rated as 20 percent disabling; right hip degenerative arthritis, rated as 10 percent disabling; left dequervain’s syndrome, rated as 10 percent disabling; left ankle sprain, rated as 10 percent disabling; and right ear hearing loss, rated as noncompensable. As of September 13, 2013, the Veteran has an overall combined rating of 100 percent. Throughout the pendency of appeal, the Veteran meets the preliminary schedular criteria for entitlement to a TDIU rating, as he has been in receipt of a single disability of at least 40 percent and a combined disability evaluation of 80 percent or more throughout the pendency of the appeal. Based upon a review of the record, the Board finds that entitlement to a TDIU is not warranted for the foregoing reasons. Pursuant to the Board’s September 2016 remand, the RO requested that the Veteran complete a VA Form 21-8940, Application for Increased Compensation Based on Unemployability. No response to this request has been received from the Veteran, and his failure to provide the requested information was noted in the RO’s November 2020 Supplemental Statement of the Case. Nevertheless, the Board notes that the record contains sufficient information regarding his education and employment history through various statements made during the pendency of the appeal. In this regard, the record shows that the Veteran had earned both an associate degree and a bachelor’s degree, and he was licensed as a church elder. He was employed as support staff with the Army National Guard until December 2012, and then he worked as a lead load operator from January 2013 to May 2013. He then maintained a full-time employment position at a VA medical center from June 2013 to September 2020, and he was last employed as a supervisor in environmental management service. See November 2014 VA Form 28-1900 Disabled Veterans Application for Vocational Rehabilitation; the Veteran’s resume received in January 2015; March 2018 report of general information; and VA medical records. A September 30, 2020 VA treatment record reflects that the Veteran reported that he recently retired due to age. Although the Veteran was eligible for a TDIU on a schedular basis throughout the pendency of the appeal since June 2012, the record demonstrates that the Veteran was employed full-time until September 2020. Moreover, there is no indication that he was employed in a family-run business, sheltered workshop, or other protected environment suggestive of marginal employment from 2012 to 2020. In light of the evidence demonstrating that the Veteran had sustained gainful employment from June 2012 to September 2020, and in the absence of any evidence or argument suggesting that his actual employment was otherwise marginal in nature, entitlement to a TDIU for the period from June 2012 to September 2020 is not warranted. See 38 C.F.R. § 4.16; Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). With respect for the period since September 2020, the Veteran has a combined 100 percent rating for his service-connected disabilities. Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of TDIU predicated on a single disability may form the basis for an award of special monthly compensation. See Bradley v. Peake, 22 Vet. App. 280, 293 (2008). Thus, the Board must consider a TDIU claim based on a single service-connected disability alone for the purpose of maximize benefits allowable. Here, the Board has reviewed all the available evidence and concludes that the preponderance of the evidence does not support a finding that the Veteran is rendered unemployable due a single service-connected disability alone. Initially, the Board notes that neither the Veteran nor his representative has identified a single service-connected disability that alone precludes the Veteran’s ability to work. In this regard, as noted above, the Veteran did not respond to VA’s April 2019 request for his assistance in obtaining records that support claim for a TDIU, and he did not provide any argument following the November 2020 supplement statement of case. Instead, the evidence shows that although the Veteran has reported that his service-connected disabilities have impacted his ability to work, he has not identified a single service-connected disability alone which precludes his employability. Notably, the Veteran himself, when reporting his retirement to his treating medical providers, did not assert his retirement was the result of a single service-connected disability. Rather, he stated he retired due to age. See September 2020 and October 2020 VA treatment records. Moreover, a review of evidence of record does not show that the Veteran has a single service-connected disability that alone precludes his ability work. Rather, these records show that the combination of the Veteran’s service-connected disabilities together have significantly impacted his ability to work. A review of the Veteran’s VA rehabilitation vocational and education folder does not show that the Veteran was considered unable to work because of a single service-connected disability. Rather, in a January 2015 VA Rehabilitation Counseling Record-Narrative Report shows that the Veteran’s physical and mental health service-connected disabilities, taken together, have significantly impacted his ability to work, and caused him to have a serious employment handicap. However, VRE record shows that the Veteran’s vocational goal was still considered reasonably feasible, despite his service-connected disabilities. An October 2015 VA psychiatric examination report noted that the Veteran’s mental health disability caused him social and occupational impairment with deficiencies in most areas, including work. His symptomatology had included flatten affect, depressed mood, impaired impulse control, social withdrawal, psychomotor agitation, paranoia, suicidal thoughts, disturbance in mood and motivation, sleep impairment. However, the VA examiner noted that medication alterations had improved his mood stability and he is not currently experiencing any hallucinations or suicidal thoughts. The report also notes that the Veteran continued to work full time for a job that required waking every morning, showering, and commuting, despite of his mental health symptomatology. May 2018 VA shoulder and back examination reports shows that the Veteran’s service-connected bilateral shoulder and back disabilities prevents him from performing overhead lifting or using his arms over 90 degrees, precludes him from heavy lifting, and he requires an ergonomic worksite for prolonged sitting. A July 2020 VA back examination report shows that the Veteran’s service-connected back disability renders him unable to perform lift heavy object, and he should avoid standing, squatting, bending, and twisting for prolonged periods. No VA examiner indicated that a single service-connected disability alone precluded the Veteran’s ability to work. Subsequent VA treatment records show that the Veteran’s back, bilateral shoulders, bilateral carpal tunnel syndrome, and left Dequervain’s disease disabilities impacted his ability to function, to include severe difficulty with activities that require use of arm, shoulder, and hand due to pain, and his back causes him decreased flexibility and difficulty with ambulating distances. He has required physical therapy to help alleviate functional loss and pain. See November 2019, April 2020, June 2020, October 2020 VA treatment records. In addition, VA mental health treatment records show that the Veteran continued to receive counseling therapy as well as psychotropic medication, which provides him with improved mood. See February 2020, March 2020, April 2020 VA mental treatment records, and October 2020 VA treatment record. No medical provider has indicated that the Veteran is unable to work due to a single service-connected disability alone. Having reviewed the above evidence, the Board finds that the weight of the evidence demonstrates that the Veteran is not unemployable due to a single service-connected disability alone since September 2020. At most, the evidence of record demonstrates that his combined service-connected disabilities significantly impacted his ability to work. The Veteran has not asserted, and the competent evidence of record does not demonstrate, that one of his disabilities alone is sufficiently severe as to render the Veteran unable to find or maintain substantially gainful employment since September 2020. Rather, the Veteran maintained full-time employment despite the severity caused by his combined service-connected disabilities throughout the majority of the period under appeal until he retired due to age in September 2020. Accordingly, the record shows that the Veteran maintained substantially gainful employment from June 2012 to September 2020, and since September 2020, the Veteran is already rated as 100 percent disabling and is not unemployable due to any one service connected disability alone. As such, the claim for TDIU is denied. REASONS FOR REMAND Entitlement to service connection for a breathing condition is remanded. The Veteran asserts that he has a breathing disorder manifested by intermittent episodes of shortness of breath and dyspnea on exertion. It remains unclear from the medical evidence of record whether the Veteran has a current disability that is related to his period of service. In both March 2014 and May 2018 VA respiratory examination reports, the VA examiners found that there was insufficient evidence to demonstrate a current pulmonary diagnosis. However, neither VA examiner commented on the Veteran’s December 2011 x-ray that shows evidence of “old granulomatous disease” during service and the similar findings observed during post-service March 2014 VA chest x-ray. Moreover, a July 2019 VA chest x-ray report reflects that old calcified granuloma in left lung base is again visible. In addition, the Veteran’s service treatment records show he was evaluated for complaints of shortness of breath, and an October 2010 Pulmonary Function Test (PFT) revealed findings of mild restrictive ventilatory defect, which were not reversed with Albuterol. Later VA treatment records show that the Veteran continue to show he complained of shortness of breath with exertion. Although he was prescribed an Albuterol inhaler to treat his intermittent symptoms of shortness of breath in May 2018, the Veteran stopped using it because it did not alleviate his symptoms. He was referred to pulmonology for further assessment management; however, any such treatment records remain outstanding and should be obtained. See December 2018 VA treatment record. Also, on remand, the Board finds that the Veteran should be afforded with a new VA respiratory examination to determine the nature and etiology of his claimed breathing disorder. The matters are REMANDED for the following actions: 1. Update the Veteran’s VA treatment records, to include any pulmonary consultation reports since December 2018. 2. Schedule the Veteran for a VA examination for his claimed breathing disorder. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is any current breathing disability at least as likely as not related to service, including complaints of shortness of breath, December 2011 x-ray findings of “old granulomatous disease”, and October 2010 PFT findings of mild restrictive ventilatory defect. Provide a rationale to support the opinion(s). Saudiee Brown Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Murray 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.