Citation Nr: 21016194 Decision Date: 03/22/21 Archive Date: 03/22/21 DOCKET NO. 06-13 905 DATE: March 22, 2021 ORDER 1. Entitlement to service connection for a neurological disability of the left lower extremity other than a sciatic nerve disorder, to include as secondary to service-connected soft tissue lacerations to the right foot and heel with residual pes planus and/or lumbosacral strain with intervertebral disc syndrome and degenerative disc disease, is denied. 2. Entitlement to an initial compensable rating for muscle atrophy of the right calf prior to September 22, 2009; in excess of 10 percent from September 22, 2009 to December 15, 2017; and in excess of 30 percent from December 16, 2017 is denied. 3. Entitlement to an initial disability rating for soft tissue lacerations to the right foot and heel with residual pes planus (pes planus) in excess of 20 percent prior to April 19, 2018; and in excess of 30 percent from April 19, 2018 is denied. 4. Entitlement to referral for extraschedular consideration of a total disability rating for compensation based on individual unemployability due to service-connected disabilities (TDIU) prior to September 22, 2009, is denied. 5. Entitlement to a schedular TDIU rating from September 22, 2009 to December 16, 2017 is denied. FINDINGS OF FACT 1. The Veteran does not have, nor has he had at any time proximate to or during the course of this appeal, a current lower left extremity neurological disability, other than a sciatic nerve disability. 2. The Veteran’s muscle atrophy of the right calf did not result in a moderate muscle disability prior to September 22, 2009, a moderately severe muscle disability from September 22, 2009 to December 15, 2017; or more than a severe muscle disability from December 15, 2017. 3. Prior to April 19, 2018, the Veteran's unilateral pes planus was not manifested by pronounced pes planus, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 4. From April 19, 2018, the Veteran's unilateral pes planus was manifested by no worse than pronounced pes planus, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 5. The preponderance of the evidence is against a finding that the Veteran has been unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities for the period on appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for a neurological disability, other than a sciatic nerve disorder, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for an initial compensable disability rating for muscle atrophy of the right calf prior to September 22, 2009; in excess of 10 percent from September 22, 2009 to December 15, 2017; and in excess of 30 percent from December 16, 2017, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.73, Diagnostic Code (DC) 5311. 3. The criteria for an increased disability rating for bilateral pes planus in excess of 20 percent prior to April 19, 2018, and in excess of 30 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5276. 4. The criteria for referral for an extraschedular TDIU rating prior to September 22, 2009 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16(b). 5. The criteria for entitlement to a TDIU rating from September 22, 2009 to December 16, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Air Force from March 1966 to January 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a March 2005 rating decision that initially granted service connection for soft tissue lacerations to the right foot and heel with residual pes planus and assigned a 20 percent rating effective from June 30, 2004. The rating decision also denied entitlement to service connection for left thigh L3 nerve group numbness to knee with sleeping; and granted service connection for muscle atrophy of the right calf and assigned a noncompensable evaluation effective from June 30, 2004. After additional evidence was received in March 2005, the Agency of Original Jurisdiction (AOJ) reconsidered and denied the service-connection claim and higher initial ratings for these disabilities in an August 2005 rating decision. See 38 C.F.R. § 3.156(b). The Veteran then filed a timely notice of disagreement (NOD) with these determinations in November 2005 and August 2006. In decisions dated in May 2009, February 2011, and December 2013, the Board remanded the issues to the AOJ for additional development and adjudication. In a May 2015 decision, the Board remanded the increased rating claims and denied entitlement to service connection for an L3 nerve group disorder causing numbness/sleeping feeling to left thigh and knee, to include as secondary to service-connected soft tissue lacerations to the right foot and heel with residual pes planus. The Veteran appealed that determination to the United States Court of Appeals for Veterans Claims (Court). In a December 2015 Order, the Court vacated that portion of the Board decision and remanded the matter to the Board for development consistent with the parties' Joint Motion for Partial Remand (Joint Motion). In an August 2016 decision, the Board assumed jurisdiction over the issue of entitlement to a TDIU rating under Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board then remanded this issue, the Veteran’s service-connection claim for a neurological disability of the left lower extremity, and the Veteran’s increased rating claims for right calf muscle atrophy and soft tissue lacerations of the right foot and heel with residual pes planus. These matters were most recently remanded in April 2020 for additional development, including performing VA examinations relating to the Veteran’s service-connection claim, which was completed in December 2020. There has been substantial compliance with the remand directives and the matters are again before the Board. See Stegall v. West, 11 Vet. App. 268 (1998). As noted in prior Board decisions, the Board had separately denied entitlement to service connection for a left lower extremity sciatic nerve disability in a May 2009 Board decision, and this determination was not appealed further. Additional consideration of entitlement to service connection for a sciatic nerve disability of the left lower extremity requires that the previously-denied claim be reopened, if appropriate. As this claim has not since been reopened, the Board has characterized the relevant service-connection claim on appeal as entitlement to service connection for a neurological disability of the left lower extremity other than a sciatic nerve disorder. In March 2007, the Veteran testified at a Decision Review Officer (DRO) hearing. A transcript from the proceeding is associated with the claims file. During the pendency of the appeal, the Veteran was awarded increased ratings for his muscle atrophy of the right calf of 10 percent effective from September 22, 2009; and 30 percent effective from December 16, 2017. He was also awarded an increased rating for the soft tissue laceration disability of 30 percent effective from April 19, 2018. As the Veteran has not withdrawn these claims, they remain in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). Service Connection In general, under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 U.S.C. § 5103(a). The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against an award of service connection for a neurological disability of the left lower extremity, other than a sciatic nerve disorder. The reasons follow. 1. Entitlement to service connection for a neurological disability of the left lower extremity other than a sciatic nerve disorder The Veteran has reported experiencing numbness in his left thigh beginning in 2007, which has subsequently spread to his left hip and knee. The Veteran has reported that attempts at treatment have not been helpful. As explained below, the weight of the evidence is against the finding of a present neurological disability in the left lower extremity, other than a sciatic nerve disorder; therefore, service connection is not warranted. Treatment notes from 2009 showed the Veteran reported pain in the lower back with intermittent numbness in the left lower extremity, which was assessed as sciatica. A November 2011 VA examination report shows the examiner found the Veteran did not have a nerve injury in the lower extremities, and the examiner documented normal reflexes and normal sensation in the left lower extremity. In August 2016, the Board directed the AOJ to obtain a VA examination and medical opinion related to the Veteran's service-connection claim for a neurological disability of the left lower extremity. An examination in response to the remand was initially obtained in September 2017, and the examiner noted diagnoses of left lumbar radiculopathy and numbness over an area of 4 inches below the left medial malleolus encamping under the surface of the heel secondary to a local injury to the right skin area. The examiner also noted diagnoses of meralgia paresthetica of the right thigh. The examiner commented in the report that the Veteran's report of back pain that radiated down the left thigh to the knee on the outside was in a typical sciatic pattern. In addition, the examiner marked in the examination report that there was mild incomplete paralysis of the left sciatic nerve. No additional left lower extremity nerve root involvement was identified, and the sensory examination of the left thigh/knee (L3/4) was normal. However, the examiner, a staff neurologist, noted that an opinion would need to be obtained from an orthopedic surgeon, as the Veteran's symptoms were mostly related to his hip, spine, and ankle/foot area. An additional examination was conducted by an orthopedic surgeon in November 2017, and the examiner noted there to be no diagnosis for a peripheral nerve disorder. The examiner further stated in the report that no nerves of the lower extremities were affected. In the accompanying opinion, the examiner wrote that the Veteran's complaints of bilateral thigh numbness had an age-related discogenic origin. The examiner also explained that there was no evidence of L3 radiculopathy. She stated that the Veteran demonstrated only mild gait abnormality showing tentativeness of right foot displacement, suggestive of back pain and not a significant neurological disability. However, the examiner’s explanation did not address the findings from the November 2017 examination that the Veteran had decreased sensation to the left thigh/knee and absent reflexes in the left ankle, prompting the Board remand in April 2020. On examination in December 2020, the examiner concluded the Veteran had sciatica of the of left lower extremity, as supported by VA treatment and examination records from 2009, 2016, and 2017. The examiner found the Veteran to have full strength in all extremities with normal reflexes, no muscle atrophy, and some decreased sensation in the left lower extremity. The examiner documented the Veteran exhibited a normal gait. The examiner concluded the Veteran had mild, incomplete paralysis of the sciatic nerve on the left side. The examiner stated that the Veteran does not have a diagnosis of a neurological disability other than sciatica, as there are no findings, signs, or symptoms to support a diagnosis, and specifically stated that the Veteran does not have neuropathy. She stated that the findings were reviewed by an orthopedist. The symptoms noted during the November 2017 examination, notably the lack of reflexes in the left ankle, were not present on this examination. The findings of both the November 2017 and December 2020 examination establish that there is no diagnosis of a neurological disability other than a sciatic nerve disability. To the extent that the Veteran believes that he has a neurological disability other than a sciatic nerve disorder, he is not competent to provide a diagnosis, as that requires medical expertise. In this regard, the question of causation involves a medical subject concerning an internal physical process with a number of precipitating factors and overlapping conditions and symptoms. As such, this issue may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. The opinion of the December 2020 VA examiner is most probative as she was able to review the entire longitudinal evidence of record while personally examining the Veteran and provided a reasoned rationale supported by the evidence, which does not show the Veteran to have a current neurological disability other than a sciatic nerve disorder. For the reasons discussed above, the weight of the evidence is against the Veteran having a neurological disability of the left lower extremity other than a sciatic nerve disorder. As the preponderance of the evidence is against the claim for service connection, the benefit of the doubt doctrine is not for application, and the Veteran’s claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding, do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. See 38 C.F.R. § 4.14. However, those provisions should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable diagnostic code. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). For background purposes, in July 1967, the Veteran was in a motorcycle accident, where he was driving a motorcycle and making a left-hand turn and was struck by an automobile on the right side, hitting the Veteran’s right lower extremity between the motorcycle and the automobile. The Veteran sustained a deep avulsion laceration of his right foot from the dorsum of the foot across just below the medial malleolus to his heel with several lacerations across his heel pad deeply. There was marked contusion, maceration, and gross contamination of the deep tissues of his medial foot and heel. The joint capsule was intact with all ligaments appearing intact. Tendons, arteries, and nerves were all documented to be grossly intact. The Veteran’s contaminated wound underwent thorough debridement with excision of a large amount of non-viable and contaminated tissue was carried out. The foot was irrigated profusely. The pre-operative impression of no tendon, nerve, or major artery injury was confirmed. The joint capsule during surgery was found to be intact. However, a large amount of heel-pad tissue was debrided. The Veteran was given a short-leg cast. He was placed on medication and “windowed for visualization of the wound.” The Veteran sustained full thickness skin loss of one of his flaps and another in the center of his medial wound. A split thickness skin graft was taken from his right thigh. He subsequently underwent physical therapy and discharged on the 48th post-accident day on convalescent leave. A January 1968 physical profile documented that the severe laceration of the right foot from July 1967 was healed, had normal function, residual flattened arch and was mildly painful on prolonged standing. The Veteran was advised to wear arch supports. The Veteran is in receipt of service connection for right leg quadriceps atrophy, muscle group 14, which is 40 percent disabling; muscle atrophy of the right calf, which has been staged as 0 percent, 10 percent, and 30 percent throughout the appeal; soft tissue lacerations to the right foot and heel with residual pes planus, which has been staged as 20 and 30 percent throughout the appeal; neurological impairment of the right foot, which is 10 percent disabling; a painful scar on the right foot, which is 10 percent disabling; and a painful scar on the right heel/ankle, which is 10 percent disabling. At the present time, he has a combined rating for his right lower extremity of 30 percent from June 2004, 40 percent from September 2009, 50 percent from November 2009, and 80 percent from December 2017. 2. Entitlement to an initial compensable rating for muscle atrophy of the right calf prior to September 22, 2009; in excess of 10 percent from September 22, 2009 to December 15, 2017; and in excess of 30 percent from December 16, 2017 The Veteran has reported that atrophy of his right calf causes him pain and gait difficulties, resulting from injures incurred in a 1967 motorcycle accident. The Veteran’s muscle atrophy of the right calf is rated under DC 5311, which involves muscle group XI, which involves propulsion of plantar flexion of the foot, including stabilization of the arch and flexion of the toes, flexion of the knee and posterior and lateral crural muscles and muscles of the calf. Under DC 5311, the following ratings apply: a noncompensable rating is warranted for slight injury, a 10 percent rating is warranted for moderate injury, a 20 percent rating is warranted for a moderately severe injury, and a 30 percent rating is warranted for severe injury. Id. Muscle injuries are evaluated in accordance with 38 C.F.R. § 4.56. The pertinent provisions of 38 C.F.R. § 4.56 are as follows: (a) An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. (b) A through-and-through injury with muscle damage shall be rated as no less than a moderate injury for each group of muscles damaged. (c) For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. (d) Under DCs 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows: (1) Slight disability of muscles--(i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles--(i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. (3) Moderately severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against an award of increased rating. The reasons follow. Prior to September 22, 2009 VA treatment notes from February 2005 indicate muscle atrophy of the right calf, with the examiner documenting that it involved only minimal functional loss. In 2006, VA records show that the Veteran’s right calf was measured at 37 centimeters, compared to his left calf measured at 42 centimeters. This was noted to result in a slight limp. While the Veteran reported that this disrupts his balance, he reported that he was able to swim, perform yardwork, and ride a bike. The Veteran underwent a VA examination in March 2007. The examiner documented that the Veteran had 4/5 muscle strength and normal muscle function in the calf. The preponderance of the evidence is against entitlement to a compensable rating prior to September 2009 for the service-connected muscle atrophy of the right calf. Treatment records generally show a simple muscle wound without debridement or infection, requiring only brief treatment. His activity levels demonstrate healing with good functional results. Objective findings include minimal scarring and no evidence of fascial defect, impaired tone retained metallic fragments, and only minimal functional limitation. A higher evaluation of 10 percent is not warranted unless there is evidence of moderate muscle disability. This would include a through and through or deep penetrating wound of short track, from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. The Veteran’s reports of his ability to swim and ride a bike without restriction, as well as findings of his normal muscle function do not support a finding of consistent loss of power, lowered fatigue threshold, fatigue-pain, or uncertainty of movement. Findings do not indicate entrance/exit scars with loss of deep fascia or muscle substance. Accordingly, a compensable initial evaluation is not supported by a preponderance of the evidence of record prior to September 22, 2009. From September 22, 2009 to December 15, 2017 The Veteran was assigned a 10 percent disability rating, effective September 22, 2009. At that time, the Veteran underwent a VA examination, which showed the Veteran to have 3-centimeter atrophy of the right calf relative to the left, which the examiner described as moderate. However, the Veteran was also found to have a normal gait and station. He stated that he could walk three to four times per day and could walk one to two miles in 20 to 30 minutes. The Veteran had intact, normal sensation in the left lower extremity. The preponderance of the evidence is against a more severe injury or significantly reduced functional abilities resulting from his right calf atrophy. The Veteran was noted to have a mild limp with some weakness and numbness. In March 2011, the Veteran’s right calf was described as stable, and he reported receiving no current treatment. In July 2013, the Veteran was described as “very active.” In July 2015, the Veteran was found to have full strength in all extremities. He reported continued biking, golfing, swimming, and gardening, and he was working part-time as a sales clerk at Ace Hardware where he reported walking 3 to 4 miles a day in the store. In March 2017, the Veteran was documented to have full strength and normal range of motion in all extremities. Findings of a moderately severe muscle injury were not present during this period to warrant an increased rating of 20 percent. Treatment records continued to show a simple muscle wound without debridement or infection, requiring only brief, periodic treatment without compromising the Veteran’s ability to perform activities of daily living. He reported only occasional use of pain medication as his primary treatment. Objective findings do not include significant calf scarring and no evidence of fascial defect, impaired tone, or retained metallic fragments. Treatment records do not show consistent complaints of particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Rather, some examination findings reflected full muscle strength and normal function while maintaining relatively high activity levels reflecting healing with good functional results. As such, the preponderance of the evidence is against an increased rating in excess of 10 percent prior to December 16, 2017.   From December 16, 2017 The Veteran was assigned a 30 percent rating effective December 16, 2017, which is the maximum rating under this DC. That month, the Veteran underwent a VA examination in which his right calf atrophy was measured at 3.5 centimeters. The Veteran denied ever using an assistive device for ambulation. Thereafter, the record reflects continued reports of pain, weakness, instability, and limp. However, treatment records since that time have reflected generally stable functioning and symptomology from previous examinations. The Veteran continued to work part time and stated that he “walks all day at work” with lots of bending, lifting, and climbing stairs and ladders. In 2018, the Veteran denied fatigue and there were clinical findings documenting normal strength and sensation in his lower extremities. In 2019, he was assessed with normal gait and coordination and reported continued independence in his activities of daily living. Medical records continued to show only conservative routine treatment, and the Veteran described himself as “very independent” in 2020. Despite the Veteran’s muscle atrophy, the Veteran continued to work part time in a physically demanding job, that, by the Veteran’s own account required the Veteran to walk several miles per day with lots of bending, lifting, and climbing stairs and ladders. This demonstrates good functional results without significant loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. The record has not shown that the Veteran’s disability picture warrants a rating higher than 30 percent, as, again, the 30 percent rating is the maximum rating under this DC. Based on the nature and history of the Veteran’s injury, his self-reported symptoms and activity levels, and the concurrent objective findings during each staged rating period, the Board finds that an increased disability rating in not warranted for muscle atrophy of the right calf during the pendency of the appeal. 38 C.F.R. §§ 4.56, 4.73, DC 5311. No additional higher or alternative ratings under a different DC is warranted. For the reasons addressed herein, the preponderance of the evidence is against an award of increased rating. 38 C.F.R. §§ 4.56, 4.73, DC 5311. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the Veteran's claim for ratings higher than what have been currently assigned throughout the appeal period is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 3. Entitlement to an initial disability rating for pes planus in excess of 20 percent prior to April 19, 2018 and in excess of 30 percent from April 19, 2018 The Veteran has reported that that he experiences pain, loss of sensation, and a loss of balance in his right foot, resulting from his 1967 motorcycle accident. The Veteran's unilateral right pes planus is rated under DC 5276. Thereunder, a 20 percent disability rating is warranted for severe unilateral flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A maximum 30 percent disability rating is warranted for pronounced unilateral pes planus, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. The Veteran was assigned a 20 percent disability rating effective June 30, 2004 and a 30 percent rating effective April 19, 2018. The Rating Schedule for rating some musculoskeletal disabilities was changed in February 2021; however, changes were not made to DC 5276 or DC 5284. The Veteran underwent a VA examination of the right foot and heel in February 2005. The Veteran exhibited a slight limp. A long, well-healed surgical scar was present from the posterior ankle inferior and distal to the medial malleolus, which was superficial with no pain or tenderness, and causing no breakdown, ulceration, disfigurement or functional limitations. A separate well-healed scar was present on the heal and was slightly hyposensitive and hypopigmented, causing no breakdown, ulceration, disfigurement, or functional limitations. A small callous was noted on the right heel. There was no abnormal shoe wear pattern. The alignment of the Achilles tendon was valgus (heel angled out), which the examiner stated was associated with pes planus. There was tenderness of the right heel, but no pain on manipulation of the right foot. Range of motion was 10 degrees on dorsiflexion; 45 degrees on plantar flexion; 30 degrees on inversion; and 20 degrees on eversion and abduction. There was no pain in all directions at 10 degrees from neutral with increased pain and fatigue, but no weakness or incoordination with five repetitions. There was no additional functional loss with repetition and an x-ray of the right ankle was normal. Only tiny calcaneal spurs were seen on weight bearing x-rays with no evidence of arthritis or degenerative disease. The regional office determined that callosities and painful motion with use and repetitive use of the right foot most nearly approximated the 20 percent disability rating under DC 5276. The Veteran underwent another VA examination in March 2007. There was numbness present over the Veteran’s scar and right heel. There was positive calcaneal callous, and orthotics were noted in both shoes. Additionally, the exam showed pes planus. Alignment of Achilles tendon non-weightbearing was minimally varus, and weightbearing was mildly valgus. There was no plantar tenderness and no pain with manipulation. There was no edema, weakness, instability, or tenderness. There was no pain on motion or additional limitation following repetitive range of motion. The Veteran had full strength in the ankle. The Veteran exhibited dorsiflexion of 0 to 10 degrees with pain at extreme, and 0 to 45 degrees on plantar flexion with no pain. The examiner assessed soft tissue lacerations to the right foot and heel with residual pes planus, as well as scars and heel numbness. On foot examination in September 2009, the Veteran exhibited a normal gait and station without the use of an assistive device and no abnormal weight bearing. His right foot had slightly less contour on the right arch. Scarring on his right foot had some cracking and tenderness but the foot exam was otherwise normal. His pes planus was described as mild. The Veteran reported that approximately every two to three weeks, his right heel scar would open and bleed, which causes pain and prevents him from walking normally, limiting his capabilities. However, he reported the general ability to walk multiple miles at a time and that he bikes and swims. In February 2010, an x-ray of the right foot continued to show mild pes planus features and the Veteran was prescribed more orthotic shoe inserts. The Veteran underwent an additional VA examination in March 2011. He reported constant pain and recorded 4/5 strength in the right foot. Although midfoot misalignment was noted to cause an altered gait, the examiner documented the Veteran exhibited normal weightbearing with no swelling or instability. The following month he reported independence with activities of daily living with occasional golfing, fishing, and gardening, despite decreased pain and sensation in the right foot. The Veteran sought treatment for right heel pain in March 2014. The Veteran stated that he had not had any other foot problems until about four months prior and that his heel pain “just started.” He reported working part time at Ace Hardware where he does heavy lifting, walks three to four miles per day in store, but stated that he could not work more than a couple days in a row due to heel pain. The Veteran exhibited an intact gait with normal reflexes and normal sensation below the right knee. In January 2016, the Veteran reported that when he experiences severe discomfort, he uses a cane for ambulation around the house and in public. Such use is predominantly not reflected in treatment records and did not appear to disrupt the Veteran’s part-time work at Ace Hardware. A statement submitted by the Veteran’s employer in May 2016 indicated that the Veteran received no special accommodations at work and the Veteran later reported that his work requires lots of walking, bending, lifting, and climbing. On examination in March 2017, the Veteran exhibited full strength and range of motion in all extremities, including the right foot. Prior to April 2018, the record does not reflect findings that would warrant the award of an increased rating in excess of 20 percent. Specifically, the record does not show “pronounced; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances.” Rather, the Veteran’s pes planus was described as mild by multiple examiners and he routinely used orthotic inserts, indicating their effectiveness, while performing part-time work that required relatively high exertion levels with regular walking, lifting, bending, and climbing, without special accommodations by his employer. The currently-assigned 20 percent rating contemplates moderate weakness and moderate functional impairment in his foot. For the foregoing reasons, the Board finds the preponderance of the evidence is against an increased disability rating in excess of 20 percent for pes planus under DC 5276 prior to April 19, 2018. Similarly, the Board notes that from April 19, 2018, the Veteran is in receipt of the maximum 30 percent disability rating for his unilateral pes planus under DC 5276; therefore, a higher schedular disability rating is not possible under this diagnostic code. The Veteran underwent a VA examination of the right foot on the effective date of the Veteran’s 30 percent disability rating. Examination revealed mild increased pronation of the right foot due to pain on medial weightbearing. The Veteran was noted to experience mild discomfort with non-weightbearing, pain with weightbearing, and pain with manipulation and passive range of motion. However, it was during this same examination that the Veteran reported that he gets most of his exercise at his part-time job with a lot of walking, bending, lifting, and climbing stairs and ladders, although he stated that he tries not to lift more than 20 pounds. The following month, he reported walking all day at work. In February 2019, he exhibited a normal gait with normal coordination and was found independent in his activities of daily living. In 2020, the Veteran reported that he has continued to be very independent. The preponderance of the evidence does not reveal objective medical findings that would warrant an increased rating in excess of the maximal schedular rating which the Veteran has been assigned since April 2018. The Board has also considered whether the Veteran is entitled to separate disability ratings for his right foot disability pursuant to the application of an alternate diagnostic code pertaining to foot disability. DC 5284 provides criteria for rating "other" foot injuries, and provides for 10, 20, and 30 percent disability ratings for moderate, moderately severe, and severe injuries, respectively, with a 40 percent disability rating for loss of use of the foot. However, the Board is mindful that the Veteran's service-connected disability of pes planus is specifically addressed by the rating criteria of DC 5276, while the plain language of DC 5284 makes it clear that it applies to "other" foot injuries, particularly those that are not otherwise provided for under the rating schedule. Although the Veteran’s pes planus is resultant of soft tissue lacerations to the right foot and heel, service connection has already been considered for all known disabilities relating to or associated with the Veteran’s pes planus disability, including the right heel and foot scars, such that consideration of other DCs is not warranted. As to these disabilities specifically noted as being associated with the Veteran’s pes planus, the Veteran is service-connected for muscle atrophy of the right calf; muscle atrophy of the right leg quadriceps; pelvic rotation; neurological impairment of the right foot; and painful scar of the right foot. Therefore, the Board concludes that DC 5276 is the most appropriate diagnostic code for rating the Veteran's service-connected unilateral pes planus. For the foregoing reasons, the preponderance of the evidence is against a disability rating in excess of 20 percent for the Veteran's pes planus prior to April 19, 2018, and against a disability rating in excess of 30 percent from that date. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the Veteran's claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. TDIU Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation because of service-connected disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, the disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and enough additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Since December 16, 2017, the Veteran has been in receipt of a 100 percent combined schedular rating. The Board notes that a grant of a 100 percent schedular rating does not necessarily render the issue of entitlement to a TDIU rating moot, as a TDIU rating could, in certain circumstances, render the Veteran eligible for special monthly compensation (SMC). SMC may be warranted if the Veteran has a 100 percent disabling rating for a single disability, and VA finds that a TDIU rating is warranted based solely on disabilities other than the disability that is rated at 100 percent. See Buie v. Shinseki, 24 Vet. App. 242 (2011); Bradley v. Peake, 22 Vet. App. 280 (2008). However, in this instance, the Veteran does not have a 100 percent disability rating for any single disability. Hence, the Board finds as fact that entitlement to a TDIU rating is moot for the period beginning on December 16, 2017. As a preliminary matter, the Veteran’s service-connected disabilities do not meet the percentage requirements for a schedular TDIU under 38 C.F.R. § 4.16(a) for the entire period on appeal, prior to December 16, 2017. The Veteran met the schedular requirements for TDIU consideration beginning September 22, 2009. Between September 2009 and December 2017, the Veteran was service-connected for muscle atrophy of the right calf associated with soft tissue lacerations to right foot and heel with residual pes planus with a 10 percent disability rating; soft tissue lacerations to the right foot and heel with residual pes planus with a 20 percent disability rating; intervertebral disc syndrome of the cervical spine with a 20 percent disability rating; left upper extremity cervical radiculopathy of the upper radicular nerve group with a 20 percent disability rating; pelvic rotation associated with soft tissue lacerations to right foot and heel with residual pes planus with a 10 percent disability rating; neurological impairment of the right foot with a 10 percent disability rating; tinnitus with a 10 percent disability rating; lumbosacral strain with intervertebral disc syndrome and degenerative disc disease with a 10 percent rating; degenerative disc disease of the cervical spine with a 10 percent disability rating; degenerative joint disease of the left knee with a 10 percent disability rating; painful scar of the right foot with a 10 percent disability rating; scars of the right ankle/heel with a 10 percent disability rating; and hearing loss of the left ear with a 0 percent disability rating. This equates to a current combined rating of 80 percent. However, prior to September 2009, the Veteran had a 40 percent combined rating, relating to the Veteran’s muscle atrophy of the right calf; soft tissue lacerations of the right foot and heel; pelvic rotation; and neurological impairment of the right foot. When the percentage requirements are not met, entitlement to a TDIU rating may be considered on an extraschedular basis when the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). The Board does not have the authority to assign an extraschedular TDIU rating in the first instance. See Bowling v. Principi, 15 Vet. App. 1 (2001). However, it may determine whether the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities, and then refer the issue to the Director of the Compensation Service, for a determination in the first instance as to whether the Veteran is entitled to a TDIU rating on an extraschedular basis under 38 C.F.R. § 4.16(b). Accordingly, prior to September 22, 2009, the Board will analyze whether the evidence of record demonstrates the need for a referral to the Director of the Compensation Service for extraschedular consideration. The Board acknowledges that the Veteran’s representative has argued that referral to the Director of Compensation Service is not required to provide the Veteran with an award of extraschedular TDIU in the first instance. The Board finds this argument to be moot, as the record does not indicate that the Veteran was precluded from performing substantial gainful employment for the duration of the appeal period, as discussed further below. "Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16. In determining whether a veteran can secure and follow a substantially gainful occupation, the Court in Ray v. Wilkie directed the Board to consider the following factors: (1) the veteran's history, education, skill, and training; (2) whether the veteran has the physical ability (both exertional and non-exertional) to perform the type of activities required by the occupation at issue; and (3) whether the veteran has the mental ability to perform the activities required by the occupation at issue. 31 Vet. App. 58, 73 (2019). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The responsibility for making the ultimate TDIU determination is placed on the adjudicator and not a medical examiner. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). A medical examiner's role is limited to describing the effects of disability upon the person's ordinary activity. See Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The Veteran is competent to testify as to facts he personally observed or described; this includes recalling what he personally felt, saw, smelled, heard, or tasted. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against a finding that the Veteran has been precluded from securing and following substantially gainful employment for the duration of the period on appeal. The reasons follow. 4. Entitlement to referral for extraschedular consideration of TDIU prior to September 22, 2009, and entitlement to TDIU from September 22, 2009 to December 15, 2017 For purposes of evaluating TDIU, the above findings regarding the Veteran’s increased rating claims are incorporated herein. The Veteran has alleged that he was prevented from performing substantially gainful activity due to his combined service-connected disabilities, as noted above, primarily resulting from his 1967 motorcycle accident, which cause pain in the in the Veteran’s back and lower extremities with balance difficulties and reduced sensation in the lower extremities, restricting his ability to lift and sit, stand, or walk for extended periods. He has also reported that hearing loss and tinnitus cause him occupational limitations due to difficulty hearing others, as well as fatigue resulting from sleep difficulties caused by tinnitus. The Veteran’s representative contends that the Veteran’s service-connected disability have precluded him from securing and following substantially gainful employment since June 2003, when he retired from full-time work as a manager at an energy company before later resuming part-time work. Although the Veteran’s attorney contends that the Veteran was incapable of substantially gainful employment as of his 2003 retirement, the record does not suggest that the Veteran was unable to continue working due to his physical disabilities. Rather, numerous notations are made in the treatment record indicating that the Veteran retired due to eligibility resulting from age or duration of employment. The Veteran also reported that prior to retirement he was regularly performing 60-hour workweeks, far exceeding the normal 40-hour workweek commonly associated with full-time employment. Treatment notes in March 2007 indicated the Veteran’s disabilities had no significant effect on his prior employment, except for increased absenteeism when his back symptoms flared, which was reported to have occurred once every three months resulting in limited mobility, although he had no incapacitating episodes in the prior 12 months. However, in February 2005, the Veteran denied missing workdays in his last years of employment due to disabilities prior to retirement in July 2003. During his 2007 hearing testimony, the Veteran reported that he was lucky to have had a desk job because if he experienced pain symptoms, he could put his feet up on his desk and close his door. Additionally, the Veteran returned to part-time work as a sales associate at Ace Hardware in November 2009. He reported working approximately three days and 24 hours per week on a seasonal basis, as the business is less busy in the summer. Vocational rehabilitation records from 2010 indicate that the Veteran was seeking opportunities to re-enter employment because the economy had drained his resources. He expressed interest in becoming a certified home inspector. The Veteran did not indicate that he was incapable of full-time work and these records do not suggest that his prior retirement was caused by his physical disabilities. The Veteran’s musculoskeletal disabilities have generally been treated relatively conservatively since his retirement, with chiropractic and acupuncture treatment, and occasional use of pain medication, as needed, as reported by the Veteran. In December 2016, the Veteran stated that he used Naprosyn for pain approximately every four to five weeks and ibuprofen or Tylenol approximately every two weeks for knee pain. In March 2007, the Veteran reported that his right foot symptoms prevented him from being able to walk more than a quarter mile without rest, but he denied experiencing flare-ups. In mid-2015, the Veteran underwent multiple evaluations relating to occupational restrictions caused by his physical disabilities. For purposes of these evaluations, definitions of exertional work levels consistent with those used in the Dictionary of Occupational Titles (DOT) were adopted, and are similarly adopted herein for purposes of TDIU consideration, as follows: “Sedentary work” requires exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from one-third to two-thirds of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. “Light work” requires exerting up to 20 pounds of force occasionally and or ten pounds of force frequently to lift, carry, push, pull or otherwise to move objects. Physical demand requirements are in excess of those for sedentary work. Even though the weight lifted may be only a negligible amount, a job should be rated light work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. On assessment in July 2015, a VA examiner indicated that the Veteran was still capable of performing light work despite his right calf atrophy and right foot pes planus symptoms. In July 2015, the Veteran was found capable of performing sedentary work in consideration of his right knee arthrosis. On VA examination in May 2016, an examiner noted the functional limitations associated with the Veteran’s left hip and thigh impairments to be instability of station; functional limitations of the Veteran’s knee and leg impairments to be limited standing and walking; limitations of the Veteran’s cervical spine condition to be limited range of motion; and functional limitations of the Veteran thoracolumbar spine disabilities to be limited standing and walking. The examiner also indicated that the Veteran’s atrophy of the right knee caused significant restrictions and that, to be able to work, the Veteran would require the use of a cane, an elevator or escalator for traversing stairs, that the Veteran could do no lifting or bending with limited standing and walking, and that the Veteran must change position every 15 to 30 minutes. The examiner still indicated that the Veteran could perform light work (it was not noted that the examiner was using the DOT definition of light work as described herein). An August 2016 VA assessment stated that the Veteran’s lower extremities would make it difficult for him to perform work that required climbing stairs or doing prolonged weightbearing. The Veteran also submitted a vocational assessment from a private vocational rehabilitation counselor (counselor) in December 2016, based on a review of the Veteran’s record and a phone interview with the Veteran. The counselor recited portions of the Veteran’s treatment history that reflect the Veteran’s various musculoskeletal disabilities and symptoms such as pain, weakness, numbness, instability of station, and limited mobility, sensation, and range of motion, resulting in the functional impairments noted above. The counselor cited to several lay statements relating to the Veteran’s symptomology following his 2003 retirement. The counselor noted that the Veteran worked part time at Ace Hardware, which t counselor described as marginal and protected work. The counselor also acknowledged that the Veteran reported that he could lift up to 20 pounds without pain, that he could sit for four hours before beginning to experience back pain, that he could only stand in one place for five minutes before his ankle began to bother him, and that he could do chores and activities such as gardening, but would need to stop after 30 to 45 minutes due to back and knee pain. Still, the counselor concluded that the Veteran’s service-connected disabilities precluded him from any type of competitive work, to include sedentary employment. He stated that the Veteran has significant impairments to prolonged walking or standing. The counselor indicated that the Veteran’s hearing loss interferes with his ability to effectively interact with others, as he often has to ask others to repeat themselves, and that tinnitus interferes with his ability to sleep leading to daytime fatigue which impacts his work functioning. He stated that the Veteran struggles in his part-time employment, despite limited hours, limited lifting, and frequent rest breaks. Despite the assessed limitations of VA examiners and the counselor, the Veteran’s reported activity levels since his 2003 retirement are not indicative of restrictions that would preclude the Veteran from all forms of substantially gainful employment. In February 2005, the Veteran reported bicycling three times per week for an hour, swimming multiple times per month, golfing regularly, and doing yardwork. Despite reported balance difficulties, he continued to report biking, swimming, and golfing throughout the relevant period, and also reported occasional gardening. In 2013, the Veteran was described as “very active.” Although the Veteran indicated that his right heel scar would restrict his mobility and activities every two to three weeks by cracking and bleeding, it did not appear to disrupt the Veteran’s part-time work, and he has not required inpatient treatment. In March 2015, the Veteran reported walking three to four miles per day at work and that he does heavy lifting at times. In March 2016, the Veteran reported regularly having to stand for several hours on concrete at work. Although the Veteran’s attorney has argued the Veteran’s work at Ace Hardware to be marginal and protected, a May 2016 statement submitted by the Veteran’s employer indicated the Veteran worked eight hours daily and 30 to 40 hours a week. When asked about concessions made to employee by reason of age or disability, the employer wrote, “N/A,” which is not applicable, which means he received no special accommodations for his disabilities in his work as a Sales Clerk. When asked about time lost from work in the last 12 months, the employer wrote, “N/A,” which would mean the Veteran was not missing work. The Veteran’s work was not indicated to be seasonal, as the Veteran has stated, and the employer wrote the Veteran had been working there since October 2011 (the Veteran reported he had been working there since October 2009 in the VA Form 21-8940). In December 2016, the Veteran sought treatment for an elbow injury suffered while golfing the prior month. Even after he received a 100 percent combined disability rating, the Veteran reported in 2018 that he walks all day at work with a lot of bending, lifting, and climbing ladders and stairs, despite continued reports of his musculoskeletal symptoms. The Veteran has maintained independence in his activities of daily living and was described as active. These findings, almost entirely based on the Veteran’s own reports of his activities levels are evidence against the above-noted assessments by the private vocational examiner and the 2016 VA examiner that suggested the Veteran to be precluded from substantial gainful employment due to the severity of limitations caused by his musculoskeletal disabilities. The May 2016 VA examiner’s assessment was internally inconsistent, indicating that the Veteran was capable of light work while also needing an assistive device and not being able to perform any bending or lifting, with position changes every 15 to 30 minutes, limitations that would preclude light work. However, these limitations, as well as those assessed by the counselor’s December 2016 assessment, are also directly contradicted by the Veteran’s own reports of his capabilities during the relevant period, which include numerous reports of golfing, bicycling, swimming, gardening, yardwork, and independence in activities of daily living. The Veteran maintained employment at Ace Hardware where he reported walking several miles per day in store, standing on concrete for hours at a time while performing occasional heavy lifting with bending and climbing ladders. He reported the ability to lift up to 20 pounds without pain to the counselor. The Veteran’s employer has documented that the Veteran did not require special accommodations to perform this work, such that he would require a cane, require frequent position changes or the ability to elevate his feet, or was unable to climb stairs. Although the Veteran contends that he was capable of performing this work part time only, the preponderance of the evidence is against a finding that the Veteran would be incapable of performing work with less exertional demands on a full-time basis, to include sedentary work. Accordingly, the opinions of the counselor and the 2016 VA examiner are of little probative value. As to the Veteran’s hearing loss and tinnitus, he has required only routine treatment and adjustments for the use of hearing aids. Despite some complaints of tinnitus waking him up and reports of occasional problems with his hearing aids malfunctioning, he has reported that he can hear people with the use of hearing aids and can talk on the telephone if he takes his hearing aid out. The Veteran maintained employment at Ace Hardware, where he received no special accommodations for his disabilities, and which job would require routine interaction and communication with the public. Medical records do not indicate communicative barriers with the Veteran based on hearing loss or tinnitus during treatment. Although the Veteran has reported that he experiences sleep difficulties and fatigue due to constant tinnitus, such findings are generally not reflected in the treatment record and the Veteran has routinely denied fatigue symptoms during physical examinations. For these reasons, the Board finds the preponderance of the evidence is against a finding that hearing loss and tinnitus cause significant vocational limitations that would preclude substantially gainful employment. The Board notes that the Veteran’s representative and the December 2016 counselor indicated that medical professionals lack expertise to determine what physical and mental abilities are required in a vocational setting, so as to discredit any assessments by medical examiners indicating that the Veteran may not be unemployable. These arguments are without merit. The medical evaluators noted above opined as to the Veteran’s ability to perform the physical requirements defined by sedentary work and light work with consideration of any accommodations that might be needed to perform such work. The Court has found that the Board can be informed by a medical examiner’s opinion on employability. Moore v. Nicholson, 21 Vet. App. 211, 218 (2007) (“The medical examiner provides a disability evaluation and the rating specialist interprets medical reports in order to match the rating with the disability.”), rev’d on other grounds sub nom. Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Additionally, the findings herein are not based on any particular opinion, but, rather, the totality of the evidence, including many of the Veteran’s own statements, which reflect his overall functioning and support the conclusion that he was capable of performing substantially gainful employment throughout the appeal period. Regarding the Veteran’s education, training, skills, and work history, the Veteran has reported that he had two years of college education and obtained an associate degree in technical/civil engineering. Following his military service, the Veteran reported working for 30 years Puget Sound Energy, before retiring in 2003. He held many positions, beginning as a draftsman/engineer and holding multiple managerial roles, most recently as Manager of Government and Community Relations. The Veteran reported working part time at Ace Hardware as a sales clerk, as described above, beginning in 2009. His employer, however, has documented that the Veteran has been working full time since October 2011. Additionally, the Veteran has reported that he has some computer skills, and the record reflects that he spends time using a computer. The Board finds that the Veteran’s education and job history demonstrates a capacity for learning, training, adaptation, and working effectively with others that is not hindered by his service-connected disabilities and which would have facilitated a return to substantially gainful employment. As stated above, the evidence supports a finding that the Veteran was physically capable of performing substantially gainful employment during the relevant period. It appears that the Veteran’s physical disabilities can be accommodated by a restriction to sedentary work, as described herein. The weight of the evidence does not suggest that the Veteran was limited beyond these restrictions and the Veteran’s own reporting of his activities support the notion that he was more than capable of performing such work. Such activities include gardening, biking, yardwork, and swimming, as well as his part-time and full-time work at Ace Hardware, where he has reported spending all day walking with regular lifting, bending, and climbing. Such findings do not indicate that the Veteran was physically restricted from working, and the Veteran has reported independence in his activities of daily living. A restriction to sedentary work would account for the Veteran’s symptoms of pain, instability, and decreased sensation, range of motion, and mobility, as well as flare-ups relating to the Veteran’s right heel scar, and would allow for completion of a full-time work schedule. Accordingly, the totality of the evidence suggests that the Veteran was physically capable of performing substantially gainful employment during the relevant period. As to the Veteran’s mental ability to perform substantially gainful employment, the Veteran has no service-connected psychiatric disorder. The Veteran’s work at Ace Hardware demonstrates his ability to effectively communicate with others, including the general public. The Veteran has recorded generally normal findings on mental status examination with normal behavior and cognitive functioning. As the Veteran’s service-connected disabilities do not cause the Veteran mental limitations, the weight of the evidence shows that the Veteran was mentally capable of performing substantially gainful employment during the relevant period. Based on the above assessment of the Veteran’s physical and mental abilities with consideration of his education, training, skills, and work history, the Board finds that the Veteran was capable of work that would result in income at the level of substantially gainful employment prior to December 2017. It appears that the Veteran was capable of performing his past work as a draftsman/engineer, and possibly also his prior management position, which he previously described as a “desk job.” The Veteran described some additional duties involving travel and community engagement to the December 2016 counselor, relating to his managerial work prior to his 2003 retirement. However, to the extent this occupation exceeded the limitations of sedentary work, there are an array of occupations that the Veteran was capable of performing. For example, given the Veteran’s computer skills, the Veteran could perform jobs that involve data entry. With data entry, the Veteran would be primarily responsible for entering data into a system. These jobs can usually be done from home and would not require significant training. Similarly, the Veteran appears capable of performing certain cashier positions, or work as a library or museum attendant, positions that would not require significant exertional output. Additionally, there is documentation that the Veteran had been working full time at Ace Hardware from October 2011 to at least May 2016, as documented by his employer, which is affirmative evidence that is capable of that type of employment. These facts are evidence against a finding that the Veteran is precluded from all forms of substantially gainful employment. For all the reasons described above, the Board finds that the preponderance of the evidence is against a finding that Veteran was precluded from all forms of substantially gainful employment throughout the appeal period. Therefore, the Veteran is not entitled to a TDIU rating or referral for extraschedular consideration of TDIU during the appeal period. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, entitlement to a TDIU rating or referral for extraschedular consideration of a TDIU rating is not warranted. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Wonderling, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.