Citation Nr: 21022549 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 10-22 909A DATE: April 16, 2021 ORDER 1. Entitlement to a rating in excess of 10 percent prior to April 4, 2012 for left lower extremity sciatica is denied. 2. Entitlement to a rating in excess of 20 percent from April 4, 2012 for left lower extremity sciatica is denied. 3. Entitlement to a rating in excess of 10 percent prior to April 4, 2012 for right lower extremity sciatica is denied. 4. Entitlement to a rating in excess of 20 percent from April 4, 2012 for right lower extremity sciatica is denied. 5. Entitlement to a rating in excess of 20 percent for type II diabetes mellitus with hypertension (diabetes mellitus) is denied. 6. Entitlement to service connection for bladder cancer, due to herbicide exposure, is granted. 7. Entitlement to service connection for a bladder disability, diagnosed as benign prostatic hyperplasia (BPH), to include as secondary to the service-connected lumbar spine disability, bilateral lower extremity sciatica, and/or diabetes mellitus, is denied. 8. Entitlement to service connection for a bowel disability, to include as secondary to the service-connected lumbar spine disability, bilateral lower extremity sciatica, and/or diabetes mellitus is denied. 9. Entitlement to referral for consideration of a total disability rating for compensation based upon individual unemployability due to service-connected disabilities (TDIU) prior to February 18, 2010 is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that prior to April 4, 2012 the left lower extremity sciatica manifested with moderate incomplete paralysis. 2. The preponderance of the evidence is against finding that from April 4, 2012 the left lower extremity sciatica manifested with moderately severe incomplete paralysis. 3. The preponderance of the evidence is against finding that prior to April 4, 2012 the right lower extremity sciatica manifested with moderate incomplete paralysis. 4. The preponderance of the evidence is against finding that from April 4, 2012 the right lower extremity sciatica manifested with moderately severe incomplete paralysis. 5. The preponderance of the evidence is against finding that diabetes mellitus manifests by requiring one or more daily injection of insulin, a restricted diet, and regulation of activities. 6. The Veteran is presumed to have been exposed to herbicide agents during service in the Republic of Vietnam and bladder cancer is a disease presumed to be due to exposure to herbicide agents. 7. The preponderance of the evidence is against a finding that the bladder disability, diagnosed as BPH, is caused or aggravated by the service-connected lumbar spine disability, bilateral lower extremity sciatica, and/or diabetes mellitus or is otherwise related to an in-service injury or disease. 8. The preponderance of the evidence of record is against finding that the Veteran has had a diagnosis of a bowel disability or symptoms causing functional impairment that affect earning capacity at any time during or approximate to the pendency of the claim. 9. The preponderance of the evidence is against finding that the service-connected disabilities cause the Veteran to be unable to secure or follow substantially gainful employment prior to February 18, 2010. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent prior to April 4, 2012 for left lower extremity sciatica have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520, 8620, 8720 (2020). 2. The criteria for entitlement to a rating in excess of 20 percent from April 4, 2012 for left lower extremity sciatica have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520, 8620, 8720 (2020). 3. The criteria for entitlement to a rating in excess of 10 percent prior to April 4, 2012 for right lower extremity sciatica have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520, 8620, 8720 (2020). 4. The criteria for entitlement to a rating in excess of 20 percent from April 4, 2012 for right lower extremity sciatica have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520, 8620, 8720 (2020). 5. The criteria for entitlement to a rating in excess of 20 percent for diabetes mellitus with hypertension have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.119, Diagnostic Code 7913 (2020). 6. The criteria for service connection for bladder cancer have been met. 38 U.S.C. §§ 1110, 1116, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 7. The criteria for entitlement to service connection for a bladder disability, diagnosed as BPH, to include as secondary to the service-connected lumbar spine disability, bilateral lower extremity sciatica, and/or diabetes mellitus, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 8. The criteria for entitlement to service connection for a bowel disability, to include as secondary to the service-connected lumbar spine disability, bilateral lower extremity sciatica, and/or diabetes mellitus, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 9. The criteria for referral for consideration of a TDIU rating prior to February 18, 2010 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1960 to April 1968. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in November 2017. The Board remanded these matters in August 2018 and October 2020 for additional development. In consideration of the appeal, the Board is satisfied there was substantial compliance with the remand directives and will proceed with review. Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of the disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. The U.S. Court of Appeals for Veterans Claims (Court) has held that, in determining the present level of a disability for an increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. 1. – 4. Entitlement to a rating in excess of 10 percent prior to April 4, 2012 and 20 percent thereafter for bilateral lower extremity sciatica The Veteran is currently in receipt of a 10 percent rating prior to April 4, 2012 and 20 percent thereafter under Diagnostic Code 8520 for bilateral lower extremity sciatica. After a thorough review of the evidence, the Board finds higher ratings are not warranted. The reasons follow. Pursuant to Diagnostic Code 8520, regarding paralysis of the sciatic nerve, a 10 percent disability rating is warranted for mild incomplete paralysis of the sciatic nerve; a 20 percent disability rating is warranted for moderate incomplete paralysis of the sciatic nerve; a 40 percent disability rating is warranted for moderately severe incomplete paralysis of the sciatic nerve; a 60 percent disability rating is warranted for severe incomplete paralysis of the sciatic nerve, with marked muscular atrophy; and a maximum schedular 80 percent disability rating is warranted for complete paralysis of the sciatic nerve, where the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.71a, Diagnostic Code 8520. The term “incomplete paralysis” as used therein indicates a degree of lost or impaired function which is substantially less than that which results from complete paralysis of these nerve groups, whether the loss is due to the varied level of the nerve lesion or to partial nerve regeneration. Id. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, such ratings are combined with application of the bilateral factor. 38 C.F.R. § 4.71a, Diagnostic Code 8520. (a) Prior to April 4, 2012 After filing his claim in May 2005, the Veteran submitted a statement in September 2005 in which he reported that pain in his lower back radiated into his leg and down to the thigh and calf. Private treatment records from November 2005 and September 2006 document that the Veteran reported pain, tingling, numbness, fatigue, and weakness in his lower extremities. The private treatment provider noted decreased sensation over the lateral calves and feet, absent reflexes in the patella and achilles, and no clonus at the ankles. Muscle strength testing was 4/5 in the right lesser toe extensors and right EHL function, but muscle strength testing was normal in the bilateral iliopsoas, quadriceps, gastrocnemius, and anterior tibialis. In May 2006, the Veteran reported that he had full paralysis in his right leg with severe pain in his thighs down through his calves. He reported this caused a decrease in his ability to walk, carry weight, and stand for more than 10 minutes at a time. VA treatment records from October 2006 document pain and numbness in both lower extremities with a notation that the Veteran had about 85 percent use of the right leg. Private treatment records from January 2007 document that pain in the legs prevented the Veteran from walking more than a short distance, and his reflexes were noted to be absent in the lower extremities. The Veteran had normal light touch sensibility. A May 2007 private EMG documented numbness and tingling in the bilateral lower extremities, with pain starting in the glutes and going all the way down to the knees. The Veteran’s gait was documented to be mildly antalgic with reduced velocity, but the provider specifically documented that there was no muscle atrophy and muscle strength testing was normal. Sensation in the lower extremities was intact to light touch but mildly reduced in the right foot and ankle to pin prick. The EMG documented polyneuropathy in the bilateral lower extremities affecting both the sensory and motor nerves. Private treatment records from August 2007 documented some improvement in his lower extremity symptomatology in that the Veteran reported that the pain had dulled somewhat. Muscle strength testing was documented to be normal, but reflexes were absent in the lower extremities. In a September 2007 statement, the Veteran reported the pain in his lower extremities was so severe that he would occasionally fall. He reported that he was going to have surgery on his lumbar spine soon, and he noted he was told that this surgery would likely reduce some of his neurological symptoms as well. Private treatment records from October 2007 documented ongoing numbness and tingling in the lower extremities, but a sensory examination of the bilateral lower extremities was described as grossly intact. Following the lumbar spine surgery, private treatment records from April 2008 document that the Veteran still has pain radiating from his buttocks to his knees, but the provider documented that sensation was intact in the lower extremities, though there was a delayed response in sensation after the fingers are no longer in contact with the skin. In a June 2008 statement, the Veteran reported that the spasms and pain in his bilateral lower extremities was nearly eliminated. He reported that he still experienced numbness in his legs and feet that continued to make his walk unstable. In August 2008, he reported that the numbness in his lower extremities was the same severity as it was prior to the surgery. A private EMG, completed in September 2008, documented that muscle strength testing was normal in the bilateral lower extremities. The nerve conduction study was unchanged in that the motor nerves had decreased amplitude suggesting polyneuropathy. The provider noted that there was mild evidence of acute denervation bilaterally. The Veteran was provided a VA examination in June 2009. The examiner documented gross sensation in the lower extremities was normal but documented that the Veteran had a diagnosis of radiculopathy in the bilateral lower extremities. At a Decision Review Officer (DRO) hearing, conducted in October 2009, the Veteran testified that he has to constantly move his legs to relieve pain, noting that the muscles in his legs are “erratic,” “dead,” and “miswired.” He testified that he felt that he had no control over his muscles. He testified that he used a scooter to get around due to his symptomology. He testified that walking was easier than sitting or standing, but that he was unable to walk long distances, and said he could walk only halfway around the block without assistance from a cane, walker, or his scooter. He testified that his lower extremities were sensitive to even the touch of a blanket and that he experienced a constant burning sensation in his lower extremities. April 2008 to May 2010 private treatment records document that the Veteran consistently reported he was unable to stand for more than 10 minutes and that it was painful to engage in even light activities of daily living. In May 2010, the Veteran began reporting a “buzzing” sensation in the extremities that he felt was incapacitating at times and aggravated by standing and walking. He also reported cramping in his calves and sensitivity issues at night. A June 2010 letter from the private provider, Dr. Jason Datta, notes that the Veteran had numbness in his lateral calves bilaterally as well as a decrease in his deep tendon reflexes in both lower extremities. Dr. Datta wrote these symptoms cause delimitations in mobility and activities of daily living and that the Veteran needed an electric scooter for longer periods of ambulation. In July and August 2010, the Veteran submitted five statements from a friend, his daughter and son, a fellow service member, and his uncle-in-law, all of whom had observed his symptoms. These statements all reported the Veteran had obvious difficulty walking and was in pain, noting that he was dependent on assistive devices, such as a wheelchair or cane, for ambulation. His daughter noted that his symptoms had gotten worse since his October 2007 lumbar spine surgery. VA Records from September 2011 documented that the Veteran had radiculopathic and sciatic symptoms of pain radiating into his bilateral lower extremities causing gait instability and significant physical limitations with some atrophy in the feet, though muscle tone was documented as normal. It was documented that the Veteran used a cane and had a slow, antalgic gait, and a Romberg test was positive. The VA treatment provider also documented decreased vibration in the feet as well as decreased pinprick in the toes, though the pinprick testing was normal at the ankles and above. The Board has carefully reviewed the evidence of record and finds the preponderance of the evidence of record is against a finding that the bilateral lower extremity sciatica and radiculopathy symptoms rose to the level of moderate incomplete paralysis prior to April 4, 2012. The Board acknowledges that the Veteran, his children, relatives, friends, and fellow servicemember are all competent to report that the Veteran exhibits difficulty walking and engaging in activities due to observable pain in his lower extremities and spine. The Veteran himself is also competent to report symptoms such as pain, tingling, and numbness in his lower extremities. However, these laypersons are not competent to ascribe these symptoms specifically to the diagnosis of bilateral lower extremity radiculopathy or sciatica versus the Veteran’s nonservice-connected knee disabilities. Furthermore, the Board finds the description of these symptoms to be less probative than the competent evidence, provided by VA examiners, VA treatment providers, and the private treatment providers in assessing the nature and severity of the disability prior to April 4, 2012. While the Veteran consistently reports more severe pain and limitations related to his lower extremity symptoms during this period of time, clinical examinations of the Veteran during this period on appeal, which assess only the Veteran’s bilateral lower extremity sciatica without noting impairment due to other disabilities, do not show symptoms that rise to a more moderate level of severity. Rather, private records from November 2005 and September 2006 specifically noted muscle strength testing was normal everywhere other than the right lesser toe extensors and right EHL function, and though abnormal in those areas, tests were suggestive only of active movement against some resistance rather than the more severe active movement against gravity. Additionally, while these treatment notes documented some decreased sensitivity and absent reflexes, sensation was not absent across the entirety of the lower extremity. Private EMGs from May 2007 and September 2008 documented that muscle strength testing was normal rather than the more severe active movement against resistance across the entire bilateral lower extremity. The EMGs did not document muscle atrophy and only a mildly antalgic gait. Furthermore, both EMGs documented sensation was largely intact, and, at most, was mildly reduced rather than absent. Additionally, private treatment records between the two EMGs also documented normal muscle strength, even with some reduction or absent reflexes. The June 2009 VA examiner also documented that sensation in the lower extremities was grossly normal. Finally, the June 2010 letter from Dr. Matta documented numbness only, and did not document pain, paresthesias, or dysesthesias, in the lower extremities. Though Dr. Matta noted that the Veteran had decreased deep tendon reflexes and mobility limitations, the Board finds diminished reflexes and numbness are still indicative of a mild disability as Dr. Matta did not report pain, paresthesias or dysesthesias, decreased sensation, significantly impaired muscle strength, or other symptoms that would be indicative of a more significant impairment. Furthermore, Dr. Matta, in noting mobility issues, did not address the impact his nonservice-connected knee disabilities had on his mobility. Given the above, the Board finds that prior to April 4, 2012, the total disability picture related to the sciatica in the bilateral lower extremities more closely approximates a mild disability of incomplete paralysis rather than the more severe moderate disability required for a 20 percent rating, and a rating in excess of 10 percent is denied. (b) From April 4, 2012 Another VA examination was conducted in April 2012. At this examination reflexes in the lower extremities were documented as 1+ in the knee and ankle, which is assigned for hypoactive reflexes. A sensory examination was normal in the upper anterior thighs and the thighs/knees, but sensation was decreased in the lower leg/ankle and in the feet/toes. A straight leg test was positive in the right but negative in the left. Pain due to radiculopathy was documented as moderate constant pain, moderate paresthesias and dysesthesias, and moderate numbness. The examiner described the severity of the radiculopathy as moderate. A private disability questionnaire from October 2012 notes that the Veteran has a loss of sensation of the bilateral lower extremities, and the examiner opined that the symptoms are moderate in the right lower extremity and severe in the left lower extremity. The examiner did not provide a rationale for the differences in severity other than noting that the Veteran exhibited weakness and imbalance and that he had pain and a bilateral drop foot with loss of sensation, weakness, loss of endurance, and fatigue in the lower extremities. A private disability questionnaire from November 2012 documented muscle spasms, muscle atrophy, muscle weakness, and an abnormal and limited gait. The examiner did not document a frequency or severity related to these symptoms before opining that the symptoms described moderately severe radiculopathy of the bilateral lower extremities. The Veteran’s spouse submitted a statement in January 2011, reporting that she noticed that the Veteran experienced pain in his legs, causing him to collapse sometimes. Another VA examination was conducted in July 2014. The examiner documented that the reflexes were 1+, suggestive of hypoactive reflexes in the knees. The reflexes in the ankles were documented to be absent. A sensory examination of the upper anterior thighs and thighs/knees was normal, but sensation was decreased in the lower legs/ankles and feet/toes. The straight leg raising test was negative in both extremities. Muscle strength testing was normal, and the Veteran did not have muscle atrophy. The examiner also documented that sensation was intact to light touch, but also documented that there were trophic changes of decreased hair growth below the knees. The examiner documented that the Veteran had an abnormal gait but opined the gait was abnormal due to the lumbar spine disability, not the bilateral lower extremity sciatica. The examiner documented that the Veteran did not exhibit symptoms of constant or intermittent pain, though there was moderate paresthesias and moderate numbness, and the examiner described the sciatica as moderate in nature. A private disability questionnaire conducted in October 2014 documented tenderness, muscle spasms, sensory loss, reflex changes, muscle atrophy, muscle weakness, abnormal gait, crepitus, and trigger points. A private disability questionnaire conducted in March 2015 documented tenderness, sensory loss, reflex changes, and abnormal gait with a loss of function due to pain and weakness in the lower extremities. The radiculopathy was described as moderately severe. Another VA examination was conducted in October 2016. The examiner documented normal muscle strength with no muscle atrophy. A reflex examination noted trace reflexes at the knees but absent reflexes at the ankles. A sensory examination documented intact sensation to light touch bilaterally. The straight leg test was negative bilaterally. The examiner documented moderate intermittent pain and weakness in the bilateral lower extremity, and the examiner documented the severity was moderate to severe. A VA examination conducted in January 2017 noted the Veteran had moderate constant pain, moderate paresthesias/dysesthesias, and moderate numbness in the bilateral lower extremities. Muscle strength testing was normal and light sense and position sense were normal, but deep tendon reflexes were absent in the bilateral knee and ankle. Vibration sense and cold sensation were absent. The examiner documented no muscle atrophy or trophic changes. At the November 2017 hearing, the Veteran testified that his feet feel like bricks and he experienced a burning sensation, weakness, and tingling in his legs. He testified that he used a cane and an electric scooter to ambulate. VA neurological records from September 2019 document that the Veteran experienced pain radiating from his spine with paresthesias, numbness, and tingling as well as a drop foot in the right and reported falling approximately four times per year. Another VA examination was conducted in November 2019. The Veteran reported that his disability had gotten worse since 2017 and that due to his lumbar spine and lower extremity sciatica, he now needed to use a wheelchair, noting that his symptoms of sciatica made walking difficult. The examiner noted moderate constant pain and severe intermittent pain, moderate paresthesias or dysesthesias and moderate numbness. Muscles strength testing was normal, but light touch sense, position sense, vibration sense, and cold sensation testing all revealed decreased senses in the bilateral lower extremities. The examiner also documented muscle atrophy in the left upper gluteal as well as trophic changes, including a loss of hair and thinning skin, in the bilateral anterior legs. The examiner noted mild incomplete paralysis of the sciatic nerve. A final VA examination was conducted in February 2021. The Veteran reported pain in the buttocks and numbness down both legs. The examiner noted that the Veteran had a tendency to fall, noting two falls in the past. Muscle strength testing was 3/5, suggestive of movement against resistance in the right lower extremity, but normal muscle strength testing in the left lower extremity. Deep tendon reflexes were absent. Vibration sense and light touch sense was decreased in the lower extremities, but there was no evidence of muscle atrophy or trophic changes. The Board has carefully reviewed the evidence of record and finds the preponderance of the evidence is against a finding that the symptomatology more closely approximates moderately severe bilateral lower extremity sciatica from April 4, 2012. VA examiners documented moderate constant pain, severe intermittent pain, moderate paresthesias/dysesthesias, and moderate numbness in the bilateral lower extremities. The Board finds that a moderately severe disability would document more symptoms described as severe than just severe intermittent pain. Muscle strength testing of the lower extremities was frequently documented to be normal throughout the period on appeal, and, at worst, muscle strength testing reveled no movement against resistance, which the Board finds is not indicative of moderately severe incomplete paralysis as opposed to the more severe findings of no movement against gravity or no muscle movement. While the Board acknowledges light touch, position sense, vibration sensation, and cold sensation testing were abnormal towards the end of the period on appeal, there were not consistently noted to be absent at all levels throughout the period on appeal. Rather, they were initially noted to be normal, and over time, though they decreased, examiners did not consistently note that the sensation was absent, which would be more suggestive of a moderately severe disability. Finally, while deep tendon reflexes in the lower extremities were documented to be absent and VA examiners started to document muscle atrophy and trophic changes later in the period on appeal, which is indicative of more significant symptomatology, given the remainder of the symptomatology that is suggestive of more moderate symptomatology, and weighing the inconsistency over time of these symptoms, the Board finds that these additional symptoms do not bring the total picture to the level of a more moderately severe incomplete paralysis. The Board acknowledges the private disability questionnaires completed in October and November 2012, October 2014, and March 2015. However, the Board finds these examinations are less probative than the VA examinations conducted in April 2012, July 2014, October 2016, January 2017, and February 2021, as they provide less detail in regard to the severity and frequency of the symptoms. The Veteran has the symptoms noted by these examiners, but the examiner’s reports that the Veteran has moderately severe symptoms is less probative as the rationale is unavailable to support that opinion given the lack of documentation related to the frequency and severity of the various reported symptoms. The Board also acknowledges the statement from the Veteran’s spouse but finds that the symptoms of pain are adequately considered by the moderate rating assigned for this period on appeal. Furthermore, the “collapse” is likely related to the abnormal gait, which, as noted by the July 2014 VA examiner, was likely related to the lumbar spine disability (which has its own rating of 40 percent), not the bilateral lower extremity sciatica. Finally, the Board acknowledges that the October 2016 VA examiner described the sciatica symptoms as moderate to severe rather than moderate. However, the Board is not bound by these characterizations by VA examiners, and, as noted above, the Board finds the symptoms during the entire period on appeal, including those noted by the October 2016 VA examiner, more closely approximate a moderate disability throughout the entire period on appeal. Given the above, the Board finds that a rating in excess of 20 percent for bilateral lower extremity sciatica from April 4, 2012 is denied. 5. Entitlement to a rating in excess of 20 percent for diabetes mellitus with hypertension The Veteran is currently in receipt of a 20 percent rating under Diagnostic Code 7913 for diabetes mellitus. After a thorough review of the evidence, the Board finds a higher rating is not warranted. The reasons follow. Diabetes mellitus is evaluated under the endocrine system, Diagnostic Code 7913. Under this Diagnostic Code, a 20 percent rating is warranted where diabetes mellitus requires one or more daily injection of insulin and restricted diet, or; oral hypoglycemic agent and restricted diet. A 40 percent rating is warranted where there is diabetes mellitus requiring one or more daily injection of insulin, restricted diet, and regulation of activities. 38 C.F.R. § 4.119, Diagnostic Code 7913. A 60 percent rating is warranted where there is diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if evaluated separately. Id. A 100 percent rating is warranted where there is diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. Id. Private treatment records from November 2005 document the Veteran was starting medication to control his diabetes mellitus. By July 2010, private treatment records document the diabetes mellitus was stable and managed with medications. A VA examination from April 2012 documented that the Veteran took an oral hypoglycemic agent, but he had no regulation of activities, visited his diabetic care provider for episodes of ketoacidosis or hypoglycemic reactions less than two times per month, had no episodes of ketoacidosis or hypoglycemic reactions requiring hospitalizations in the last year, and had no loss of strength or weight. A private disability questionnaire completed in October 2012 documented that the diabetes mellitus required a restricted diet, regulation of activities, and the use of an oral hypoglycemic agent, but noted that the Veteran had no ketoacidosis or hypoglycemic reactions requiring hospitalizations in the last year. A June 2014 VA examination documented diabetes mellitus with a restricted diet and the use of an oral hypoglycemic reaction, but documented that the Veteran did not regulate his activities, visit his diabetic care provider for episodes of ketoacidosis or hypoglycemia two times per month or more, have any hospitalizations in the last year for hypoglycemic reactions or ketoacidosis, or have any weight loss or loss of strength related to his diabetes mellitus. January 2017 and October 2017 VA examinations noted the diabetes mellitus was managed by a restricted diet and an oral hypoglycemic with no regulation of activities. The examiner also noted that the Veteran visited his diabetic care provider less than two times per month for episodes of hypoglycemia or ketoacidosis and had no episodes in the last year related to hypoglycemia or ketoacidosis. In accordance with Diagnostic Code 7913, note 1, the Board will first consider the complications of diabetes mellitus. In this regard, the Veteran has been awarded separate, compensable disability ratings for his complications of peripheral neuropathy of the bilateral upper and lower extremities and urinary incontinence. At the November 2017 hearing, the Veteran testified that he experienced shaking symptoms if his blood sugar got too low, though he noted that he does not require insulin and uses an oral medication only. He testified that he had never been hospitalized related to his diabetes mellitus. A November 2019 VA examination documented that the Veteran did not see his diabetic care provider two times per month or more and had not had any hospitalizations for ketoacidosis or hypoglycemia, nor did his diabetes mellitus require a regulation of his activities. It was also documented that he did not have unintentional weight loss or loss of strength. The examiner documented that the Veteran did not have hypertension. As the preponderance of the evidence does not support a finding that symptoms of diabetes mellitus require one or more daily injection of insulin, the Veteran does not meet the criteria for a 40 percent rating for diabetes mellitus, a rating in excess of 20 percent for diabetes mellitus is denied. Additionally, Diagnostic Code 7913 notes that compensable complications of diabetes mellitus are to be rated separately unless they are part of the criteria used to support a 100 percent evaluation; noncompensable complications are considered part of the diabetic process under Diagnostic Code 7913. 38 C.F.R. § 4.119, Diagnostic Code 7913 and Note 1. Throughout the record, there had been some discrepancy related to whether or not the Veteran had peripheral neuropathy of the bilateral lower extremities related to his diabetes mellitus as well as bilateral lower extremity sciatica. Various treatment records speculate an association with diabetes mellitus. However, some providers and examiners document that the Veteran did not have peripheral neuropathy associated with diabetes mellitus, while other providers and examiners seemed to assume peripheral neuropathy associated with diabetes mellitus. To clarify this diagnosis and etiology, the Board remanded this issue in October 2020. In February 2021, a VA examiner opined that the Veteran did not have a diagnosis of peripheral neuropathy associated with diabetes mellitus, and the lower extremity symptoms were entirely related to the bilateral lower extremity sciatica. The VA examiner noted that it can be difficult to separate radiculopathy from diabetic peripheral neuropathy in an uncontrolled diabetic patient. However, in this case, the Veteran’s diabetes mellitus is well controlled, and thus, it is not difficult to opine that the Veteran does not have diabetic peripheral neuropathy. The Board finds this opinion is highly probative and has attributed all symptomatology associated with the bilateral lower extremities to the rating assigned for the bilateral lower extremity sciatica. The Veteran is already in receipt of a separately compensable rating for diabetic nephropathy/renal disfunction. Thus, these symptoms will not be assessed herein. The only remaining complication of the diabetes mellitus is hypertension. The Board finds that a separate, compensable rating is not warranted for hypertension. Diagnostic Code 7101 provides ratings for hypertensive vascular disease (hypertension and isolated systolic hypertension). Hypertensive vascular disease with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control, is rated 10 percent disabling. Hypertensive vascular disease with diastolic pressure predominantly 110 or more; or, systolic pressure predominantly 200 or more, is rated 20 percent disabling. Hypertensive vascular disease with diastolic pressure predominantly 120 or more is rated 40 percent disabling. Hypertensive vascular disease with diastolic pressure predominantly 130 or more is rated 60 percent disabling. 38 C.F.R. § 4.104, Diagnostic Code 7101. A November 2019 VA examination documented that the hypertension was controlled with continuous medication, and the three readings taken on the date of examination documented blood pressure readings of 140/80, 150/80, and 144/80. There were no other pertinent findings related to the hypertension. A thorough review of the claims file notes that blood pressure readings throughout VA treatment records and private records are generally consistent with or better than the blood pressure readings noted on this examination with the exception of June 2019 records which document a blood pressure reading of 160/80. Given that a systolic pressure reading of 160 was documented infrequently, the Board finds this does not rise to the level of systolic pressure predominantly over 160 or more as required for a compensable rating. While the Veteran takes continuous medication to treat his hypertension, the preponderance of the evidence is against a finding that the Veteran has a history of diastolic pressure predominantly 100 or more. A 10 percent rating requires both continuous medication and a history of diastolic pressure predominantly 100 or systolic pressure predominantly 160 or more. As the Veteran meets neither criterion, a separate, compensable rating for hypertension associated with diabetes mellitus is denied. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). 6. Entitlement to service connection for bladder cancer, due to herbicide exposure If a Veteran was exposed to an “herbicide agent,” such as Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam from January 9, 1962, to May 7, 1975, then, absent affirmative evidence to the contrary, certain diseases will be service-connected even if there is no in-service record of the disease in service. 38 C.F.R. § 3.307(a)(6), (d), 3.309(e). Notwithstanding the foregoing presumptions, a Veteran is not precluded from establishing service connection due to exposure to herbicides with proof of direct causation. Combee v. Brown, 38 F.3d 1039, 1042 (Fed. Cir. 1994). The Veteran served on active duty from June 1965 to April 1968, which included service in Vietnam. The evidence shows that the Veteran was diagnosed with bladder cancer in January 2020. The enumerated disease associated with herbicide exposure have recently been amended to include bladder cancer. 38 U.S.C. § 1116(a)(2). As the Veteran is presumed to have been exposed to herbicide agents during service and bladder cancer is a disease presumed to be due to exposure to herbicide agents, the Board finds that service connection for bladder cancer is warranted, and the claim is granted. 7. Entitlement to service connection for a bladder disability, diagnosed as BPH, to include as secondary to the service-connected lumbar spine disability, bilateral lower extremity sciatica, and/or diabetes mellitus The Veteran testified at his November 2017 hearing that he believed that his nerve disabilities have caused his bladder incontinence. At his November 2019 VA examination, the Veteran reported that he believed his bladder dysfunction was related to the pain in his lumbar spine because he has had bladder incontinence since his fall in 1966 while on active duty. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a bladder disability. The reasons follow. As to evidence of a current disability, a November 2019 VA examination report shows that the Veteran was diagnosed with BPH and urinary incontinence. The February 2021 VA examiner clarified that the only diagnosis is BPH and newly diagnosed bladder cancer, and the incontinence and dribbling were merely symptoms of this diagnosis rather than a separate diagnosis. The Board finds the opinion of the February 2021 VA examiner is more probative as to the specifics of the current diagnosis as the opinion is fully supported by a rationale that references the facts of the file, whereas the November 2019 VA examiner did not provide a rationale for including the second diagnosis of urinary incontinence and based the second diagnosis on the notations from the providers in the claims file. Initially, the Board notes that the Veteran’s main assertion is that his BPH is caused or aggravated by his lumbar spine disability, bilateral lower extremity sciatica, and/or diabetes mellitus. Thus, the Board will address this assertion first. As to service connection as secondary to diabetes mellitus, the February 2021 examiner noted that the Veteran does not have a diagnosis of peripheral neuropathy as secondary to his diabetes mellitus, which is fully explained below. Thus, the nerve issues the Veteran asserts are causing his bladder disability are not related to his diagnosis of diabetes mellitus. As to whether the lumbar spine disability and/or lower extremity radiculopathy/sciatica caused or aggravated his diagnosed BPH, the February 2021 examiner opined that it was less likely than not that either of these disabilities caused or aggravated BPH. The examiner acknowledged that the Veteran had some symptomatology of difficulty starting a stream and incontinence related to his fall and spinal injury in service as well as related to his 2007 lumbar spine surgery. However, the examiner noted that these symptoms are common in men who have BPH after receiving anesthesia, such as would likely have been the case with this Veteran, causing his symptoms in 2007. The examiner noted that many men are diagnosed with BPH after surgery because the early minor symptoms are most apparent after anesthesia. The examiner also noted that BPH is a common age-associated condition related to prostate gland enlargement, and that this was the most likely cause of the symptoms of incontinence and difficulty urinating. Furthermore, the examiner noted that the nerves controlling bladder function go through the spinal cord and then the lumbar spinal column. He wrote that nerve damage can be caused in many ways, including childbirth, straining during bowel movements, spinal cord injury, or stroke, and in cases where disc herniation or spinal stenosis is severe (beyond typical low back pain and leg pain). However, the examiner opined that the Veteran did not have such severe symptomatology, and therefore ultimately opined that the BPH was not at least as likely as not caused or aggravated beyond their natural progression by the service connected lumbar spine disability, including the related lower extremity sciatica. The Board finds that the February 2021 VA medical opinion is highly probative, as the examiner carefully and completely reviewed the file, the Veteran’s report of history, and provided a detailed rationale for the opinion that relied on the specific facts of the case, which facts are accurate. This is evidence against a nexus between the current disability and the service-connected diabetes mellitus, lumbar spine disability, and/or bilateral lower extremity sciatica. The Board acknowledges the July 2011 private treatment records that note that the Veteran has a bladder issue that is secondary to his spine injury. However, this opinion does not include a rationale in support of the opinion, nor was it based upon an entire review of the claims file. Thus, the Board finds this opinion, without a rationale, is not probative. Regardless, it is outweighed by the opinion of the February 2021 VA examiner. The Board also acknowledges the July 2014 VA examiners opinion that the Veteran has a progressive bladder control problem that may be due to diabetes mellitus. However, that examiner also noted that he would defer to the opinion of a specialist for a more conclusive opinion. Thus, the Board finds this opinion is also less probative than the opinion provided by the February 2021 VA examiner. Thus, the Board finds that the preponderance of the evidence is against finding that current BPH is caused or aggravated by the service-connected diabetes mellitus, lumbar spine disability, and/or bilateral lower extremity sciatica. Despite not meeting the requirements for service connection on a secondary basis, the Board will still address whether the currently-diagnosed BPH can be service connected on a direct basis. As to evidence of an in-service disease or injury, the service treatment records (STRs) show that the Veteran reported some symptomatology related to his bladder disability in service. In July 1966, the Veteran reported experiencing difficulty starting a urine stream and mild dysuria. It was documented to potentially be the result of damage from the fall in which he injured his lumbar spine. However, the Veteran reported by August 1966, just days after his initial injury, that his symptoms had resolved. On his separation examination, he reported having had a history of occasional painful urination, though he noted the cause had not been determined. Thus, the facts establish that the second element of a service-connection claim is met. However, as to evidence of a nexus between the current disability and service, the Board finds that this element of a service-connection claim is not met. The November 2019 VA examiner opined that the current diagnosis of BPH was less likely than not related to an in-service incident, disease, or injury. The examiner acknowledged the testimony that the Veteran believed his current symptoms had an onset in 1966 after his fall in service. However, the examiner, after reviewing the record, noted that the claims file did not support an onset in 1966. Rather, the examiner found that the complaints of incontinence following the fall in 1966 resolved, and the claims file does not document significant symptomatology of a weak stream, difficulty initiating a stream, or incontinence until approximately 2006, just prior to the lumbar spine surgery. Furthermore, the examiner noted that between 1966 and 2006, the claims file documents that the Veteran consistently denied incontinence or other symptoms related to his later-diagnosed BPH. The Board finds these facts reported by the examiner are accurate. Thus, the Board finds the probative evidence of record is against finding that the bladder disability is at least as likely as not directly related to service. While the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to directly link the current bladder disability to service or a service-connected disability, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinions are nonprobative evidence. Additionally, the Board notes that the November 2021 VA examiner specifically opined that the Veteran’s bladder cancer was a completely separate diagnosis. Thus, the Board finds that the BPH diagnosis and the symptoms associated with BPH are not indicative of an onset of bladder cancer. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine 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. Thus, the claim for service connection for a bladder disability, diagnosed as BPH, is denied. 8. Entitlement to service connection for a bowel disability, to include as secondary to the service-connected lumbar spine disability, bilateral lower extremity sciatica, and/or diabetes mellitus The Veteran testified at his November 2017 hearing that he believed that the nerves related to his bowels are lacking, causing his bowel to loosen. He believes this could be due to his lumbar spine disability, his bilateral lower extremity sciatica, and/or his diabetes mellitus. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a bowel disability. The reasons follow. The Board concludes that the Veteran does not have a current diagnosis related to his bowel symptoms and has not had a disability at any time during the pendency of the claim or recent to the filing of the claim, to include a disability that causes functional impairment of earning capacity. Prior to the November 2019 VA examination, the Veteran did not have a diagnosed bowel disability noted in his claims file. At the November 2019 VA examination, the examiner diagnosed the Veteran with irritable bowel syndrome (IBS) from the date of that examination. At a subsequent examination, conducted in February 2021, the examiner opined that the Veteran did not have a diagnosis of IBS and has never had a diagnosis of IBS. The Board finds this to be the most probative opinion as the examiner clearly documented the entirety of the record, including his bowel symptoms in service, his 2007 lumbar spine surgery, the November 2019 VA examination, and his more recent 2020 surgery for bladder cancer. Initially, the February 2021 examiner noted that the diagnosis of IBS, made by the November 2019 examiner, was diagnosed based on the Veteran’s reported history alone. The Board finds that the opinion of the February 2021 examiner that the diagnosis of IBS by the November 2019 examiner was based on a reported history alone rather than the record is the more probative opinion. The Board finds the history reported to the November 2019 VA examiner is less credible and inconsistent with the remainder of the claims file. At the November 2019 VA examination, the Veteran reported that he thought his IBS was brought on by stress and that he often had symptoms within minutes of eating. While the Board acknowledges that the Veteran is competent to report this symptomatology, the Board finds these reports of symptoms to the November 2019 VA examiner are less credible as the remainder of the treatment records in the claims file do not document that the Veteran was reporting these symptoms. Rather, the Veteran reported to treatment providers throughout the claims file that he believed his symptoms were related to a nerve issue, which he reiterated at his November 2017 hearing. At the hearing, he did not testify to symptoms after eating or due to stress. He testified that he felt as though standing up caused his intestines to release. VA and private treatment records during the period on appeal consistently document that the Veteran reported bowel leakage, often while urinating, which he consistently associated with his nerve difficulties over the years. He also consistently reported muscle weakness causing fecal seepage. The February 2021 VA examiner noted that IBS is usually manifested by abdominal cramping, urgent stooling several times in success following eating or drinking, or by stress. The Veteran, at this examination, denied these symptoms, and the remainder of the claims file, as noted above, are consistent with the Veteran’s report to the February 2021 VA examiner. The examiner noted that the most recent symptoms are related to his 2020 bladder surgery. Prior to that, the only diagnosis of IBS in the file was made by the November 2019 VA examiner, which, again, the February 2021 VA examiner noted was based on history alone rather than specific facts in the record. Thus, the Board finds the most probative evidence of record is against finding that the Veteran has a diagnosed bowel disability, including IBS. The claims file documents symptomatology associated with his bowel at various points during the period on appeal. In Saunders v. Wilkie, the U.S. Court of Appeals for the Federal Circuit held that “‘disability’ in § 1110 refers to the functional impairment of earning capacity,” and to establish the presence of a disability, a Veteran will need to show that [his or] her pain reaches the level of a functional impairment of earning capacity.” Id. at 1367–68. Since filing this claim, private treatment records and VA treatment records document that the Veteran reported occasional bowel incontinence or leaking. The Veteran testified that when he urinates, his bowels will loosen, noting that he had some feeling. He reported that sometimes his bowel releases and he will have to go to the bathroom immediately. He testified that he no longer goes out to eat because of these symptoms. Since his 2020 bladder surgery, the Veteran reports soft and loose stool and a lack of regular bowel movements. The Board finds the Veteran’s reported symptoms documented throughout the claims file related to his bowels do not cause functional impairment of earning capacity. While these symptoms may require the Veteran to be near a bathroom, reasonable accommodations can be made to allow the Veteran to work near a bathroom in many employment situations. Beyond that, many roles can be completed from the home, where the Veteran would be able to use his own bathroom. Additionally, and most probatively, the Board notes that the Veteran frequently throughout the period on appeal did not report any symptoms related to bowel symptomatology. The vast majority of the symptoms related to his bowel incontinence were noted prior to the period on appeal and related to the 2007 lumbar spine surgery. After that, and until approximately 2019, when the Veteran had the November 2019 VA examination and reported symptoms inconsistent with the remainder of the record, the Veteran’s claims file, more often than not, are negative for reports of bowel problems or dysfunction. Thus, for the vast majority of the period on appeal, the most probative evidence supports a finding that the Veteran did not regularly have significant symptoms of bowel incontinence that would impact his functional capacity. Thus, the Veteran cannot satisfy the basic compensation statutes. A claim for symptoms alone, absent a diagnosis or showing of functional impairment of earning capacity due to these symptoms, is an insufficient factual showing. Consequently, the Board does not have evidence to establish that the Veteran has a current disability manifested by bowel symptoms. Absent a current disability, service connection must be denied on both a direct and secondary basis. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine 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. Thus, the claim for service connection for a bowel disability is denied. TDIU 9. Entitlement to a TDIU rating prior to February 18, 2010 A TDIU rating may be granted upon a showing that the veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 C.F.R. § 4.16(a). There are minimum disability rating percentages that must be shown for the service-connected disabilities, alone or in combination, to even qualify for consideration for a TDIU award under § 4.16(a). Indeed, if there is only one such disability, it must be rated at 60 percent or more; if instead there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. Id. If a veteran does not meet the aforementioned criteria, a total disability may still be assigned, but on a different basis. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). Therefore, the rating boards are required to submit to the Director, Compensation Service, for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage of standards set forth in 38 C.F.R. § 4.16(a). Id. In determining whether a veteran is unemployable for VA purposes, consideration may be given to the veteran’s level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. A veteran need not show 100 percent unemployability in order to be entitled to a TDIU. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). 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 Court has held that the central inquiry in determining whether a veteran is entitled to a TDIU is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). The test of individual unemployability is whether a veteran, as a result of his or her service-connected disabilities alone, is unable to secure or follow any form of substantially gainful occupation which is consistent with his or her educational and occupational experience. 38 C.F.R. § 3.340, 3.341, 4.16. The Board also notes that the ultimate question of whether a veteran is capable of substantial gainful employment is not a medical one; rather, that determination is for the adjudicator. 38 C.F.R. § 4.16(a); Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Prior to February 18, 2010, the Veteran was service connected for a lumbar spine disability at a rating of 10 percent prior to July 3, 2009 and 40 percent thereafter; a right shoulder disability at a rating of 10 percent prior to June 24, 2010 and 20 percent thereafter; left lower extremity sciatica at a rate of 10 percent, and right lower extremity sciatica at a rate of 10 percent. The Veteran was also in receipt of a noncompensable rating for a right trapezius scar. The combined rating is 40 percent from May 16, 2006 to July 2, 2009 and 60 percent from July 3, 2009 to February 17, 2010. As the Veteran does not have a combined total rating over 70 percent or a single disability rated at 60 percent or more, the schedular criteria for TDIU have not been met. Regardless, the Board will consider whether referral for extraschedular consideration for TDIU is warranted. While in service, the Veteran performed aircraft maintenance and was an aircraft inspector. Following active service, the Veteran worked in management as a manufacturing and technology analyst at Cessna, Northrop, and/or Boeing for 25 to 30 years. He retired in October 2003. The Veteran testified at his November 2017 hearing that he obtained his Associates degree and also received management training throughout his career. The Veteran reported to SSA examiners that his work history helped him develop skills in managing people, managing budgets and resources, coordinating technical responsibilities, and working with computers. Social Security Administration (SSA) records document that the Veteran received disability from SSA in 2004 due to his lumbar spine disability, knee disability, and carpal tunnel syndrome. Notably, the knee disability and carpal tunnel syndrome are not service-connected disabilities. SSA records also document significant impact from a left eye disability and arthritis in the knees and shoulders (the right shoulder is a service-connected disability during the period on appeal). The Veteran reported to SSA that his inability to reach and his bad knees precluded him from working in his field. In July 2004, the Veteran’s spouse reported to SSA that the Veteran was able to do basic yard work, go to stores and shop online, play golf (though she did note that playing golf had become more painful), restore a boat, and care for animals, but she also reported that he was no longer able to go on long walks or drives without symptoms related to carpal tunnel syndrome. The Veteran’s spouse reported that the Veteran was able to concentrate, follow instructions, and did not have memory issues or memory loss. In May 2004, the Veteran reported to SSA that he is able to go outside, shop for groceries, prepare meals, engage in daily activities, check email, restore an old boat, and that he enjoyed woodworking. He reported difficulty with physical activities such as kneeling, squatting, climbing stairs, and standing for more than 20 minutes. The Veteran reported that his main concerns were arthritis in his hips and knees as well as pain in his upper extremities. The Veteran reported in September 2005 that his bilateral lower extremity sciatica impaired his ability to lift, walk, and stand. A VA examiner in September 2007 documented that the right shoulder disability would have a moderate impact on his ability to engage in activities of daily living, but would no impact on his ability to travel, eat, bathe, dress, or groom himself. Initially, the Board notes that the Veteran reported to a June 2009 VA examiner that his lumbar spine did not cause him to retire, and July 2006 private treatment records document that the Veteran retired unrelated to any specific disability, but rather because he had been working at the same company for 25 to 30 years. However, at the October 2009 DRO hearing, the Veteran reported that he retired in part because it was just too hard to walk around and do his job, which required a lot of walking and sitting. At his November 2017 hearing, the Veteran also testified that he retired because he could no longer sit or walk as required for his job, though he also noted that he was scheduled for a knee replacement that also impacted his decision to retire as he would have many restrictions following the surgery. The Board notes that the knee disability is not service connected. Despite reporting that he retired in part due to an upcoming knee surgery, the Veteran testified that he believed his lumbar spine disability alone would have prevented him from performing full-time work starting in May 2006 because he could no longer sit or stand for long periods of time and could not walk. He also testified that working at a computer would have been hard because of the time he would have to spend sitting versus getting up and moving around. On the April 2015 VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, the Veteran reported that his lumbar spine disability, right shoulder disability, and bilateral lower extremity disabilities prevent him from securing or following substantially gainful employment, noting that he last worked in October 2003, which is when he retired from Boeing. While the lumbar spine disability, right shoulder disability, and bilateral lower extremities impact the Veteran’s ability to engage in physical activity, as noted by VA examiners and the Veteran’s own reports, and would require the Veteran to have some flexibility to sit, stand, or move around to accommodate his various symptoms, the Board finds the preponderance of the evidence is against finding that the service-connected disabilities prevented him from securing or following a substantially gainful employment prior to February 18, 2010. Rather, though somewhat physically limited, most office jobs, including telemarketing and data entry, which do not require significant educational history or training, would allow the Veteran to engage in employment with minimal accomodation to allow him to stand or sit as necessary. The Veteran’s managerial experience, experience with computers, and ability to coordinate responsibility would more than qualify the Veteran for these types of positions and would not be significantly limited by his service-connected disabilities, which cause only some physical impairment for which reasonable accommodations could be made. Additionally, the Board finds that the SSA records weigh against a finding that the service-connected disabilities were the main cause of his decision to retire in October 2004 and further support a finding that from 2005 to 2010, the service-connected disabilities were not so severe as to impair the Veteran’s ability to maintain substantially gainful employment. SSA disability was awarded based in part on a lumbar spine disability, carpal tunnel syndrome, and a knee disability. Notably, the Veteran is not service connected for a knee disability or carpal tunnel syndrome. Additionally, the Board notes that, as of 2004, the Veteran’s spouse was reporting that the carpal tunnel syndrome had a significant impact on his ability to drive or engage in physical activity, rather than the service-connected disabilities. The Veteran also reported in May 2004 that his hips, knees, and upper extremity pain were his main concerns as of May 2004, which are not service-connected disabilities, with the exception of the right shoulder. The Board acknowledges the opinion of the November 2012 private treatment provider, Dr. Datta, in which Dr. Datta, who had treated the Veteran since 2006, opined that the disabilities prevented him from standing for more than 30 minutes, lifting more than 10 pounds frequently, or sitting for more than three hours consecutively. Dr. Datta opined that the Veteran would be unable to stand or walk continuously in a work setting. Dr. Datta also noted that the physical symptoms were frequently severe enough to impair the Veteran’s attention and concentration, requiring frequent, short, and unscheduled breaks throughout the workday. Dr. Datta noted that these symptoms had been present and this severe since 2006. Initially, the Board notes that this opinion does not specify precisely which disabilities would cause these impairments. Since February 2010 and November 2012, the Veteran was awarded service connection for a left lower extremity crushed gluteal muscle, and major depressive disorder. Notably, later VA examinations note that the crushed gluteal muscle specifically further impacts the Veteran’s ability to walk, stand, or sit for prolonged periods of time. Furthermore, the disabilities, which were service connected prior to February 18, 2010 have, in some cases, increased in severity between February 2010 and November 2012 when Dr. Datta provided this opinion. Dr. Datta does not clarify which disabilities caused the symptomatology that would impair the Veteran’s ability to work, dating back to 2006, and presumably included disabilities for which the Veteran was not yet service connected or for which the Veteran has never been service connected. As TDIU contemplates only those disabilities for which the Veteran has received service connection at the time of the award of entitlement to TDIU, the opinion of Dr. Datta is not highly probative. Furthermore, Dr. Datta does not discuss the increasing severity of the Veteran’s symptoms from 2006 to 2012, facts that are apparent in the record. Finally, Dr. Datta did not discuss the SSA records, which document that as of 2004 the Veteran’s spouse was not reporting any issues with concentration, memory loss, or inability to follow instructions, symptoms Dr. Datta reported impacted the Veteran in such a way as to impair employability by 2006. The Board finds these inconsistencies and inadequacies in the opinions provided by Dr. Datta weigh against the probative value of this opinion. Thus, the Board finds the evidence supports a finding that the Veteran is physically capable of performing substantially gainful employment prior to February 18, 2010 based on the physical limitations of his service-connected disabilities only. The Veteran’s lumbar spine disability, right shoulder disability, and lower extremity sciatica, prior to February 18, 2010 did cause some limitation in physical capability. However, as noted above, many of the Veteran’s reports in regard to his physical limitations were due to his knees, hips, and carpal tunnel syndrome, which are not service-connected disabilities, and, though the Veteran has occasionally reported that physical limitations, including his lower extremity sciatica and lumbar spine, were the driving factor behind his decision to retire, the records show that a pending knee surgery was a major contributing factor, which is not a service-connected disability. While the Veteran may have been precluded from returning to his previous employment, as it required significant walking, it appears that the Veteran’s service-connected physical limitations could have been reasonably accommodated in positions that utilized his management and computer skills, such as many office or telemarketing positions. Additionally, the standard for TDIU is not whether the Veteran can continue his previous employment, but rather, whether the Veteran is unable to secure or follow substantially gainful employment generally. The Board notes that the Veteran is not service connection for a psychiatric disability, and though the November 2012 private opinion by Dr. Datta has asserted that the Veteran’s physical disabilities have impaired his ability to mentally concentrate and focus, the Board has found that opinion to be less probative given that it contradicts and is inconsistent with the contemporaneous medical records and the prior statements of the Veteran and his spouse to SSA, as described above. Furthermore, prior to February 2010 the records available show that the Veteran had normal psychiatric reviews with the preponderance of the records noting no abnormal findings in private treatment records, including a failure to find abnormalities in thought content or process, insight or judgment, mood or affect, or notations of anxiety, depression, or suicidal ideation. The Board finds that the preponderance of the probative evidence of record supports a finding that the Veteran’s service-connected disabilities did not impair the mental abilities of the Veteran. For all the reasons laid out above, the Board finds the preponderance of the evidence is against a finding that the Veteran would be precluded from securing or following a substantially gainful employment due to the service-connected disabilities, and referral for extraschedular consideration for a TDIU rating is not warranted. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Keninger, 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.