Citation Nr: 21021678 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 18-20 904 DATE: April 13, 2021 ORDER Service connection for a headache disorder is denied. Service connection for a bilateral knee disorder is denied. Service connection for a bilateral ankle disorder is denied. Service connection for chondrosarcoma of the brain, to include as due to an undiagnosed illness or other qualifying chronic disability, and to include as due to exposure to environmental hazards, is denied. A temporary total disability rating based upon hospital treatment in excess of 21 days is denied. A temporary total disability rating based on postoperative convalescence is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The Veteran’s headache disorder, bilateral knee disorder, and bilateral ankle disorder were not shown in service or for many years thereafter and are not otherwise etiologically related to active duty service. 2. The Veteran’s and chondrosarcoma of the brain was not shown in service or for many years thereafter and is not otherwise etiologically related to active duty service, to include as due to an undiagnosed illness. 3. Throughout the period on appeal, the Veteran did not have a hospitalization in excess of 21 days for a service-connected disability. 4. Throughout the period on appeal, the Veteran did not have a period of convalescence for a service-connected disability. 5. The evidence does not indicate that the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for a headache disorder have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 2. The criteria for service connection for a bilateral knee disorder have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 3. The criteria for service connection for a bilateral ankle disorder have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 4. The criteria for service connection for chondrosarcoma of the brain, to include as due to an undiagnosed illness or other qualifying chronic disability, and to include as due to exposure to environmental hazards have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.317. 5. The criteria for a temporary total disability rating based upon hospital treatment in excess of 21 days have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.29. 6. The criteria for a temporary total disability rating based upon postoperative convalescence have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.30. 7. The criteria for TDIU have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1996 to March 1999. In January 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. Service Connection The Veteran is seeking service connection for a headache disorder, a bilateral knee disorder, a bilateral ankle disorder, and chondrosarcoma of the brain. 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); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases may be presumed to have been incurred during service if they become manifested to a compensable degree within one year from separation from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). This presumption is rebuttable by affirmative evidence to the contrary. Id. Moreover, evidence of continuous symptoms since active duty is a factor for consideration as to whether a causal relationship exists between an in-service injury or incident and the current disorder as is contemplated under 38 C.F.R. § 3.303(a). Service connection may be warranted on a presumptive basis for veterans with service in the Southwest Asia theater of operations for objective indications of a “qualifying chronic disability” that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). Service connection is also warranted for a disability that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for a headache disorder 2. Entitlement to service connection for a bilateral knee disorder 3. Entitlement to service connection for a bilateral ankle disorder 4. Entitlement to service connection for chondrosarcoma of the brain, to include as due to an undiagnosed illness or other qualifying chronic disability, and to include as due to exposure to environmental hazards The Veteran contends that service connection is warranted for a headache disorder, a bilateral knee disorder, a bilateral ankle disorder, and chondrosarcoma of the brain because his current disorders are related to his active duty service. With respect to a headache disorder, the Veteran contends that service connection is warranted because the evidence shows that his current headaches began during or are otherwise related to his active duty service because he experienced severe headaches during his active duty service. He also appears to suggest that his headaches have been aggravated by his chondrosarcoma of the brain. The Veteran also contends that service connection is warranted for his bilateral knee and ankle disorder because they began during or are otherwise related to his active duty service. Specifically, with respect to his bilateral knee disorder, he asserts that because he began experiencing symptoms related to a bilateral knee disorder a “couple of years” after his separation from service and because he participated in no other activities that could have caused such symptoms, his bilateral knee disorder is related to his active duty service. With respect to his bilateral ankle disorder, he asserts that service connection is warranted because he injured his ankles during active duty, was treated for those injuries, and that his current bilateral ankle disorder is related to those injuries. With respect to chondrosarcoma in the brain, the Veteran contends that service connection is warranted because he was exposed to environmental toxins during his active duty service that caused him to develop chondrosarcoma of the brain. Based upon the evidence of record, the Board determines that although the Veteran has current diagnoses of a headache disorder, a bilateral knee disorder, a bilateral ankle disorder, and chondrosarcoma in the brain, service connection is not warranted because the preponderance of the evidence weighs against finding that these disorders began during service or are otherwise etiologically related to active duty service. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303(a), (d), 3.304, 3.307, 3.309, 3.310. Initially, the Board finds that the Veteran’s service treatment records fail to establish that his headache disorder, bilateral knee disorder, bilateral ankle disorder, and chondrosarcoma in the brain were incurred in or are otherwise etiologically related to his active duty service. Here, his service treatment records do not reflect that he reported symptoms of, received treatment for, or was diagnosed with a headache disorder, a bilateral knee disorder, a right ankle disorder, or chondrosarcoma in the brain. In fact, the report from his October 1998 separation examination reflects that the examining physician determined that his lower extremities were normal and does not reflect that the examining physician determined that the Veteran had a diagnosis or symptoms of a headache disorder and chondrosarcoma in the brain. Moreover, the October 1998 report of medical history reflects that the Veteran reported that he was in “good health,” denied having “trick” or locked knee, swollen or painful joints, and frequent or severe headaches, and did not report experiencing or having symptoms of chondrosarcoma in the brain or a right ankle disorder. Thus, his service treatment records fail to show that his headache disorder, bilateral knee disorder, right ankle disorder, and chondrosarcoma in the brain were incurred in or are otherwise etiologically related to his active duty service. With respect to a left ankle disorder, the Board acknowledges that November 1996 service treatment records reflect that he reported that he experienced left ankle pain after twisting his left ankle when stepping in a hole, and that he was diagnosed with a sprained ankle. Nevertheless, the November 1996 service treatment records do not establish that his left ankle disorder was incurred during active duty service or is otherwise etiologically related to his active duty service because his service treatment records show that this was a discrete injury that resolved and did result in chronic symptoms or a diagnosis of a left ankle disorder. In fact, the October 1998 report of medical history reflects that he denied swollen or painful joints and does not reflect that he reported that he had an ankle disorder or symptoms of an ankle disorder, and the report from the October 1998 separation examination reflects that the examining physician determined that his lower extremities were normal. Thus, his service treatment records also fail to establish that service connection is warranted for his left ankle disorder. The post-service clinical evidence also fails to establish a relationship between the Veteran’s headache disorder, bilateral ankle disorder, and bilateral knee disorder. Specifically, the post-service evidence of record does not reflect a diagnosis of, that he sought treatment for, or that he reported signs or symptoms of an a bilateral ankle disorder or a bilateral knee disorder until December 2013, more than 14 years after his separation from service, and a headache disorder until February 2013, more than 13 years after his separation from service. Given the significant gaps between his separation from service and when he first sought treatment for these disorders, a continuity of symptoms based upon the clinical evidence is not sufficient to support a direct nexus, including for purposes of the chronic disease presumption under 38 C.F.R. § 3.307(a)(3). With respect to chondrosarcoma in the brain, he is not truly asserting that he has experienced continuous symptoms, and rather is asserting that his exposure to toxins during his deployment caused him to develop this disorder. Nevertheless, if he was asserting a continuity of symptoms of chondrosarcoma it would not be established by the evidence because the evidence shows that he did not seek treatment for chondrosarcoma in the brain until November 2012, more than 13 years after his separation from service. The Board acknowledges the Veteran’s statements regarding the history of his symptoms of a headache disorder, a bilateral knee disorder, and a bilateral ankle disorder, including that he began experiencing severe headaches during his active duty service, that he injured his ankles during service, and that he began experiencing symptoms of a knee disorder a “couple” of years after his separation from service. Although he is competent to report that he has experienced symptoms of these disorders, he is not competent to determine that these symptoms were manifestations of a particular disorder. See Jandreau, 492 F.3d at 1377, 1377 n.4. Nevertheless, to the extent he contends that these disorders were caused by active duty service and have persisted since service, the Board determines that the reported history of continued symptoms is not probative in establishing the nexus element because the evidence shows that he did not seek treatment for a headache disorder until more than 13 years after his separation from service, a bilateral knee disorder until more than 14 years after his separation from service, and a bilateral ankle disorder until more than 14 years after his separation from service. The fact that he did not seek treatment for these significant durations after his active duty service weighs against his credibility. See Kahana v. Shinseki, 24 Vet. App. 428, 439-40 (2011). Further, the Board finds that the October 1998 report of medical history and the report from the October 1998 separation examination weigh against the Veteran’s credibility in asserting continuous symptoms. Specifically, the October 1998 report of medical history weighs against his credibility in asserting continuous symptoms because it reflects that he denied having “trick” or locked knee, swollen or painful joints, and frequent or severe headaches. The report from the October 1998 separation examination weighs against his credibility in asserting continuous symptoms because it reflects that the examining physician determined that his lower extremities were normal and did not note that the Veteran experienced headaches. Additionally, service connection may be granted when the evidence establishes a medical nexus between active duty service and the current diagnosis. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran’s headache disorder, bilateral knee disorder, bilateral ankle disorder, and chondrosarcoma in the brain to his active duty service, despite his contentions to the contrary. The Board initially notes that there is no objective medical evidence linking the Veteran’s headache disorder, bilateral knee disorder, bilateral ankle disorder, and chondrosarcoma in the brain to an event during his active duty service. Next, the Board places great probative weight on the VA examinations considering the etiological relationship between his headache disorder, bilateral knee disorder, bilateral ankle disorder, and chondrosarcoma of the brain and his active duty service. With respect to a headache disorder, the report from the June 2014 VA examination reflects that the examiner opined that it would be only with resort to mere speculation to opine whether the Veteran’s headaches were caused or aggravated to any degree by his military service. In support of that opinion, the examiner explained that it would be speculative to attribute his headache disorder to his active duty service because no treatment for headaches was documented by his service treatment records, he denied headaches in the October 1998 report of medical history, and had a normal neurological examination at that time. Further, the examiner explained that although environmental exposures related to service in Southwest Asia are noted to cause temporary headaches, the current medical literature does not support a cause and effect relationship between those exposures and the development or persistence of a chronic headache condition, and that there was no objective evidence that his environmental exposures caused or aggravated his headaches. With respect to a bilateral knee disorder, the report from the June 2014 VA examination reflects that the examiner opined that it would be only with resort to mere speculation to opine whether the Veteran’s bilateral knee disorder was caused or aggravated to any degree by his military service. In support of that opinion, the examiner explained that it would be speculative to attribute his bilateral knee disorder to his active duty service because his service treatment records did not document any knee injuries, symptoms of a knee disorder, treatment for a knee disorder, or diagnoses of a knee disorder, his October 1998 report of medical history reflected that he denied any joint or knee problems, and the report from his October 1998 separation examination documented a normal musculoskeletal examination. With respect to a bilateral ankle disorder, the report from the June 2014 VA examination reflects that the examiner opined that it would be only with resort to mere speculation to opine whether the Veteran’s bilateral ankle disorder was caused or aggravated to any degree by his military service. In support of that opinion, the examiner explained that although his service treatment records reflect that he sustained a left ankle sprain in November 1996, they did not otherwise document any ankle injuries, symptoms of an ankle disorder, or diagnoses of an ankle disorder, his October 1998 report of medical history reflected that he denied any joint problems, and the report from his October 1998 separation examination documented a normal musculoskeletal examination. Further, the examiner supported his opinion by explaining that the objective evidence failed to show that the Veteran’s left ankle sprain was more than an acute and transitory event or that it could have caused or aggravated his current bilateral ankle arthritis. The report from a March 2018 VA examination reflects that the examiner did not diagnose the Veteran with a right ankle disorder and opined that his left ankle disorder was less likely than not incurred in or caused by his active duty service. In support of that opinion, the examiner explained that degenerative changes to the ankle do not result from or relate to acute soft tissue injuries such as strains or sprains and, in this case, the service treatment records showed that the Veteran sustained an ankle sprain. The examiner also supported that opinion by noting that there was no indication of chronic or recurrent left ankle complaints in the service treatment records, and that the Veteran had denied ankle problems by denying that he experienced swollen or painful joints in the October 1998 report of medical history. With respect to chondrosarcoma in the brain, the report from the June 2014 VA examination reflects that the examiner opined that it would be only with resort to mere speculation to opine whether the Veteran’s chondrosarcoma in the brain was caused or aggravated to any degree by his military service. In support of that opinion, the examiner explained that it would be speculative to attribute his chondrosarcoma of the brain to his active duty service because the current medical literature does not support a cause and effect relationship between those exposures and the development of a brain tumor, and that there was no objective evidence that his environmental exposures caused or aggravated his brain tumor. Additionally, the examiner explained that although the chondrosarcoma of the brain document in the Veteran could be slow growing, required 10 to 15 years to be detected, and may have began growing during his active duty service without detection, it was not possible to objective determine the precise time of the onset of his chondrosarcoma in the brain and whether it could have been during his active duty service. Given the expertise of these VA examiners, their reviews of the claims file, and their well-supported rationales, including citations to medical literature where relevant, the Board finds that their opinions are entitled to substantial probative weight. The Board acknowledges that the evidence of record includes positive February 2018 private opinions. With respect to the Veteran’s bilateral knee disorder, a February 2018 private opinion reflects that a private physician opined that his chronic knee pain was more likely than not the result of his active duty service. With respect to the Veteran’s chondrosarcoma in the brain, a February 2018 private opinion reflects that a private physician opined that it was his professional opinion that it was more likely than not that the Veteran’s chondrosarcoma in the brain was a direct result of his exposure to toxins during his military service. In support of that opinion, the physician stated that in his professional experience and in the medical literature it was “known” that toxins could have carcinogenic potential resulting in the development of rare tumors in young patients, and that a review of the medical history and circumstances and events of the Veteran’s military service included that the Veteran was exposed to toxins. The Board finds that these private opinions are not probative of whether the Veteran’s bilateral knee disorder and chondrosarcoma in the brain are related to his active duty service because they are not entitled to significant probative weight. With respect to both the February 2018 private opinion concerning his bilateral knee disorder and the February 2018 private opinion concerning his chondrosarcoma in the brain, the Board concludes that it is not entitled to significant probative weight because there is no indication that the physician reviewed the complete medical evidence, including his service treatment records. Moreover, the opinion provided regarding his bilateral knee disorder is not entitled to probative weight because the physician’s opinion is conclusory given that it fails to provide any rationale supporting the conclusion that his bilateral knee disorder is etiologically related to his active duty service. The Board also finds that the opinion concerning his chondrosarcoma in the brain is not entitled to probative because it is conclusive, as it does not support the opinion that his chondrosarcoma of the brain is related to toxin exposure with information concerning the duration of such exposure, his proximity to toxins, the type of toxins he was exposed to, and which specific toxins can have carcinogenic potential resulting in the development of rare tumors in young patients. The Board also notes that to the extent that the Veteran contends that his chondrosarcoma in the brain is related to exposure to toxins during his deployment to the Southwest Asia theater of operations, the Board concludes that there is not sufficient evidence to establish a nexus between his chondrosarcoma of the brain and toxin exposure. Specifically, there is no information as to how long he was exposed to toxins, his proximity to toxins, the type of toxins that he was exposed to, or other such information that would be necessary to show a relationship between his toxin exposure and chondrosarcoma of the brain. In arriving at its conclusion, the Board has also considered the statements made by the Veteran relating his headache disorder, bilateral knee disorder, bilateral ankle disorder, and chondrosarcoma in the brain to his active duty service. The Federal Circuit has held that “[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau, 492 F.3d at 1377). In this case, however, the Veteran is not competent to provide testimony regarding the etiology of his headache disorder, bilateral knee disorder, bilateral ankle disorder, and chondrosarcoma in the brain. See Jandreau, 492 F.3d at 1377, n.4. Although he can provide competent testimony regarding symptoms, these are not disorders that can be diagnosed by their unique and identifiable features as they do not involve a simple identification that a layperson is competent to make. In any event, the diagnoses of dysfunctions and disorders, and their respective etiologies, are medical determinations and generally must be established by medical findings and opinion. See id. at 1376-77. Thus, to the extent that the Veteran believes that these disorders are related to his active duty service, he is a lay person without appropriate medical training and expertise to provide a medical diagnosis and etiological opinion. Additionally, to the extent that the Veteran asserts that his headache disorder is secondary to his chondrosarcoma in the brain, the Board notes that it has found that service connection for chondrosarcoma in the brain is not warranted. Given that service connection cannot be granted as secondary to a nonservice-connected condition, secondary service connection for his headache disorder is not warranted. See 38 C.F.R. § 3.310. By virtue of the foregoing, the Board concludes that service connection for a headache disorder, a bilateral knee disorder, a bilateral ankle disorder, and chondrosarcoma in the brain is not warranted. Temporary Total Disability Rating 5. Entitlement to a temporary total disability rating based upon hospital treatment in excess of 21 days 6. Entitlement to a temporary total disability rating based upon postoperative convalescence The Veteran contends that a temporary total disability rating is warranted based upon hospital treatment in excess of 21 days for treatment related to his chondrosarcoma in the brain and based upon postoperative convalescence related to a surgical procedure performed to treat his chondrosarcoma in the brain. A temporary total evaluation may be assigned without regard to other provisions in the rating schedule when it is established that a service-connected disability required hospital treatment for a period in excess of 21 days or hospital observation at a VA’s expense for a service-connected disability for a period in excess of 21 days. 38 C.F.R. § 4.29. A temporary 100 percent evaluation may also be assigned when it is established that a service-connected disability required surgery necessitating at least one month of convalescence, surgery with severe postoperative residuals, or treatment with immobilization by cast of one major joint or more. 38 C.F.R. § 4.30. The Court of Appeals of Veteran’s Claims has defined convalescence as “the stage of recovery following an attack of disease, a surgical operation, or an injury.” Felden v. West, 11 Vet. App. 427, 430 (1998) (citing Dorland’s Illustrated Medical Dictionary 415 (30th ed., 2003)). The Court also defined recovery as “the act of regaining or returning toward a normal or healthy state.” Id. (citing Webster’s Medical Desk Dictionary 606 (1986)). In other words, the purpose of a temporary total evaluation pursuant to 38 C.F.R. § 4.30 is to aid the Veteran during the immediate post-surgical period when he may have incompletely healed wounds or may be wheelchair-bound, or when there may be similar circumstances indicative of transient incapacitation associated with recuperation from the immediate effects of an operation. The Court has also held that notations in the medical record as to the Veteran’s incapacity to work after surgery must be taken into account in the evaluation of a claim brought under the provisions of 38 C.F.R. § 4.30. See Seals v. Brown, 8 Vet. App. 291, 296-297 (1995); Felden, 11 Vet. App. at 430. After a review of the evidence of record, the Board concludes that a temporary total evaluation is not warranted based upon hospital treatment in excess of 21 days or postoperative convalescence the Board has denied service connection for chondrosarcoma in the brain, the disorder that caused the Veteran to receive hospital treatment and for which a surgical procedure was performed by a surgeon. Given that temporary total evaluations are only available for the treatment of service-connected disabilities and that the Veteran’s chondrosarcoma in the brain is not a service-connected disability, the Veteran’s claims fail to meet the threshold requirement of 38 C.F.R. §§ 4.29 and 4.30 and must be denied as a matter of law. TDIU 7. Entitlement to TDIU The Veteran contends that TDIU is warranted in this case. The Veteran principally contends that his chondrosarcoma in the brain has prevented him for being able to secure or follow a substantially gainful occupation. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). The Board must consider if the Veteran can obtain employment more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce to be the poverty threshold for one person. See Ray v. Wilkie, 2019 U.S. App. Vet. Claims LEXIS 386 (Mar. 14, 2019). Further, the Board should also consider whether given the Veteran’s history, education, skill, and training, in conjunction with the Veteran’s physical ability and mental ability, can perform the type of activities required by the occupation at issue. See Id. Moreover, the Board must evaluate whether there are circumstances in the Veteran’s case, apart from any non-service-connected conditions and advancing age, which would justify TDIU. 38 C.F.R. §§ 3.341(a), 4.19; See Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). A total disability rating for compensation purposes may be assigned on the basis of “individual unemployability,” or when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. In such an instance, if there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). If a veteran fails to meet the threshold minimum percentage standards enunciated in 38 C.F.R. § 4.16(a), rating boards should refer to the Director of Compensation and Pension Service for extra-schedular consideration all cases where the veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). Thus, the Board must evaluate whether there are circumstances in the Veteran’s case, apart from any non-service-connected conditions and advancing age, which would justify TDIU. 38 C.F.R. §§ 3.341(a), 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The veteran’s service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). After a review of the evidence of record, the Board determines that TDIU is not warranted because the Veteran’s service-connected disabilities do not prevent him from securing or following a substantially gainful occupation. As a threshold matter, the Veteran does not meet the schedular criteria for TDIU for any portion of the period on appeal. Specifically, his service-connected left wrist disability has been rated as 10 percent disabling (effective January 31, 2014), his service-connected right wrist disability has been rated as 10 percent disabling (effective January 31, 2014), his service-connected tinnitus has been rated as 10 percent disabling (effective January 31, 2014), and his service connected left wrist scar has been rated as noncompensable (effective January 31, 2014), for a total combined rating of 30 percent. Thus, he does not meet the schedular criteria for TDIU because he does not have a combined rating of 70 percent or a single disability rated as 40 percent disabling. Next, the Board finds that referral for extraschedular consideration is not warranted because the Veteran’s service-connected disabilities do not prevent him from securing or following a substantially gainful occupation. See 38 C.F.R. § 4.16(b). Here, the medical evidence does not indicate that the Veteran’s service-connected disabilities prevented him from securing or following a substantially gainful occupation. With respect to his service connected left and right wrist disabilities, the report form the June 2014 VA examination reflects that the examiner determined that those disabilities had functional impact only to the extent that those disabilities prevented him from doing pushups and caused him to experience difficulties when applying force or torque with either wrist, limiting his ability to perform many manual tasks. However, the examiner also noted that those disabilities did not preclude limited duty or sedentary employment. With respect to his service-connected left wrist disability and left wrist scar, the report from the March 2018 VA examination reflects that the examiner determined that his left wrist disability and left wrist scar did not impact his ability to perform any type of occupational task. With respect to his service-connected tinnitus, the report from the June 2014 VA examination reflects that the examiner determined that his tinnitus did not impact his ability to work. The Board also notes that the Veteran’s treatment records do not reflect that his service-connected disabilities have prevented him from securing or following a substantially gainful occupation. Given that the examiner’s found that the June 2014 VA examiner found that the Veteran’s right and left wrist disabilities caused limited functional impact that did not preclude him from limited duty or sedentary employment, and that the June 2014 tinnitus examiner and March 2018 wrist conditions examiner did not find that his disabilities caused any functional impact, the Board cannot conclude that his service-connected disabilities have prevented him from securing or following a substantially gainful occupation. Indeed, the Veteran does not truly contend that these service-connected disabilities have prevented him from securing or following a substantially gainful occupation. Instead, he principally contends that his chondrosarcoma in the brain has prevented him from securing or following a substantially gainful occupation. However, because the Board has not granted service connection for chondrosarcoma in the brain, it cannot be used to support a grant of TDIU. The Board also notes that the Veteran is a high school graduate who worked full time as a truck driver and part time as a cook. His service-connected disabilities have not prevented him from performing the duties of a truck driver or a cook. Instead, as noted above, his nonservice-connected chondrosarcoma of the brain caused him to be unable to perform such duties. Thus, the Board finds that his service-connected disabilities do not prevent him from securing or following a substantially gainful occupation. Moreover, the Board finds that the clinical evidence is sufficient for the Board to make its own conclusions. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner). In this regard, the Board also notes the most probative evidence, including the reports from the June 2013 and March 2018 VA examination, does not support a finding that referral for extraschedular TDIU consideration is warranted. By virtue of the foregoing, the Board concludes that service connection for a headache disorder, a bilateral knee disorder, a bilateral ankle disorder, and chondrosarcoma in the brain is not warranted, a temporary total evaluation is not warranted, and TDIU is not warranted. 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. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Crosnicker, Associate Counsel