Citation Nr: 21023042 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 15-16 485 DATE: April 20, 2021 ORDER Entitlement to a disability rating of 20 percent, but not more, for right elbow osteochondritis dissecans is granted on and after March 23, 2010, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a disability rating of 20 percent, but not more, for limitation of pronation in right elbow osteochondritis dissecans is granted on and after March 23, 2010, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 10 percent for acne vulgaris of the chest and back is denied. Entitlement to a total rating based on unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. On and after March 23, 2010, the Veteran’s right elbow osteochondritis dissecans manifested as limitation of flexion to 90 degrees and limitation of pronation with motion lost beyond the last quarter of the arc, but not ankylosis, limitation of flexion to 70 degrees, limitation of extension to 45 degrees, impairment of the flail joint, joint fracture with deformity, nonunion, impairment of the ulna or radius, or limitation of pronation with motion lost beyond the middle of the arc. 2. During the period on appeal, the Veteran’s acne vulgaris of the chest and back has not manifested as deep acne affecting 40 percent or more of the face and neck, deep acne affecting the intertriginous areas, or scarring or disfigurement. 3. During the period on appeal, the Veteran’s service-connected disabilities did not preclude him from performing gainful employment for which his education and occupational experience would otherwise qualify him. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran’s favor, on and after March 23, 2010, the criteria for a rating of 20 percent, but no higher, for right elbow osteochondritis dissecans have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5206 (2020). 2. With resolution of reasonable doubt in the Veteran’s favor, on and after March 23, 2010, the criteria for a rating of 20 percent, but no higher, for limitation of pronation in right elbow osteochondritis dissecans have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5213 (2020). 3. The criteria for a rating in excess of 10 percent for acne vulgaris of the chest and back have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.118, Diagnostic Code 7828 (2020). 4. The criteria for an award of a TDIU have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from June 1970 to March 1973, including service in the Vietnam War. These matters are on appeal a November 2011 rating decision. In March 2018, the Veteran testified at a hearing before a Veterans Law Judge. A transcript is of record. In January 2021, the Veteran was notified that the Veterans Law Judge who held the March 2018 hearing is no longer available to participate in the decision. He was provided the opportunity to appear at another Board hearing and instructed that, if he did not respond within 30 days, the Board would assume that he did not want another hearing and proceed accordingly. Because more than 30 days have elapsed and the Veteran did not respond, the Board will consider the claims on the evidence of record. These matters were previously remanded by the Board in August 2018 for an attempt to obtain additional records and to afford the Veteran additional VA examinations. The Agency of Original Jurisdiction (AOJ) has done so. The June 2019 VA examinations are adequate because they were based upon consideration of the Veteran’s pertinent medical history, his lay assertions and current complaints, and because they describe his right elbow and skin disabilities in detail sufficient to allow the Board to make fully informed determinations. There was therefore substantial compliance with the remand directives with regard to the issues being decided below. See Stegall v. West, 11 Vet. App. 268 (1998). The increased rating claims on appeal stemmed from the Veteran’s March 2020 claim for a TDIU. Because, in that claim, the Veteran ascribed his unemployability in part to his right elbow disabilities and his acne vulgaris, the Board finds that the issue of entitlement to a TDIU has been raised in connection with the claims on appeal for increased ratings. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4 (2020). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. “Staged” ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When entitlement to compensation has already been established and an increased rating is at issue, the relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart, 21 Vet. App. at 509; see also 38 U.S.C. § 5110(b)(2) (2012); 38 C.F.R. § 3.400(o)(2) (2019). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Factors of joint disability include increased or limited motion, weakened movement, excess fatigability, incoordination, and painful movement, including during flare-ups and after repeated use. DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. § 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Additionally, “pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system.” Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Pain in a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id.; 38 C.F.R. § 4.40. Under 38 C.F.R. § 4.59, painful joints are entitled to at least the minimum compensable rating for the joint. In this case, at least the minimum compensable ratings have been in effect during the entire appeal period. Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). 1. Right Elbow Osteochondritis Dissecans 2. Limitation of Pronation in Right Elbow Osteochondritis Dissecans The Veteran contends that his right elbow osteochondritis dissecans warrants higher ratings than those currently assigned. It is currently rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5206, with a 10 percent rating from March 31, 1973 to April 28, 2019 and a 20 percent rating on and after April 29, 2019. He also has a separate 20 percent rating for limitation of pronation in right elbow osteochondritis dissecans on and after April 29, 2019. VA received the Veteran’s claim for an increased rating on March 23, 2010. Hyphenated diagnostic codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2020). Diagnostic Code 5010 pertains to traumatic arthritis and Diagnostic Code 5206 pertains to limitation of forearm flexion. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes “to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities.” Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran’s claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that are more favorable to the Veteran will be applied. Prior to the amendment, Diagnostic Code 5010 provided for rating as degenerative arthritis under Diagnostic Code 5003. Diagnostic Code 5003 provided, when limitation of motion is noncompensable under the appropriate Diagnostic Code, for a 10 percent rating for each major joint or group of minor joints affected by limitation of motion. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. For rating purposes, the elbow is considered a major joint. 38 C.F.R. § 4.45. As the Veteran’s disability rating is already based on painful motion prior to April 29, 2019 and on compensable limitation of motion afterward, further discussion of Diagnostic Code 5010 under the pre-amendment criteria is not warranted. After the amendment, Diagnostic Code 5010 provides for rating as limitation of motion, dislocation, or other specified instability under the affected joint. As the Veteran’s right elbow disability is already rated based on compensable limitation of motion on and after April 29, 2019, further discussion of Diagnostic Code 5010 under the amended criteria is also not warranted. The amendments did not change Diagnostic Codes 5206 or 5213. The Veteran is right-handed. Limitation of flexion of the forearm in the major extremity is evaluated as follows: flexion limited to 45 degrees (50 percent); flexion limited to 55 degrees (40 percent); flexion limited to 70 degrees (30 percent); flexion limited to 90 degrees (20 percent); flexion limited to 100 degrees (10 percent); and flexion limited to 110 degrees (noncompensable). 38 C.F.R. § 4.71a, Diagnostic Code 5206. Limitation of extension of the forearm in the major extremity is rated as follows: extension limited to 110 degrees (50 percent); extension limited to 100 degrees (40 percent); extension limited to 90 degrees (30 percent); extension limited to 75 degrees (20 percent); and extension limited to 60 or 45 degrees (10 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5207 (2020). A 20 percent rating is warranted if flexion is limited to 100 degrees and extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5208 (2020). Impairment of supination and pronation of an elbow in the major extremity is evaluated as follows: bone fusion with the hand fixed in supination or hyper pronation (40 percent); bone fusion with the hand fixed in full pronation (30 percent); bone fusion with the hand fixed near the middle of the arc, or moderate pronation (20 percent); pronation lost beyond the middle of the arc (30 percent); pronation lost beyond the last quarter of the arc (20 percent); and limitation of supination to 30 degrees or less (10 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5213 (2020). For VA purposes, a normal range of forearm motion is pronation from 0 to 80 degrees and supination from 0 to 85 degrees. 38 C.F.R. § 4.71, Plate I (2020). There are additional Diagnostic Codes that apply to elbow and forearm disorders. 38 C.F.R. § 4.45(f) (2020). 38 C.F.R. § 4.71a, Diagnostic Code 5205 (2020) pertains to ankylosis of the elbow. Joint fracture with marked cubitus varus or cubitus valgus deformity or with ununited fracture of head of radius warrants a 20 percent rating. § 4.71a, Diagnostic Code 5209 (2020). Nonunion of the radius and ulna with flail false joint in the major extremity warrants a 50 percent rating. § 4.71a, Diagnostic Code 5210 (2020). Impairment of the ulna in the major extremity is evaluated as follows: nonunion in upper half with false movement, loss of bone substance, and marked deformity (40 percent); nonunion in upper half without loss of bone substance or deformity (30 percent); nonunion in lower half (20 percent); and malunion with bad alignment (10 percent). § 4.71a, Diagnostic Code 5211 (2020). Impairment of the radius in the major extremity is evaluated as follows: nonunion in lower half with false movement, loss of bone substance, and marked deformity (40 percent); nonunion in lower half without loss of bone substance or deformity (30 percent); nonunion in upper half (20 percent); and malunion with bad alignment (10 percent). § 4.71a, Diagnostic Code 5212 (2020). The Veteran was afforded a VA examination for joint disabilities in June 2010. The Veteran reported chronic elbow pain and that his symptoms were consistent day to day without flare ups. He reported that he could not do push-ups, lift anything heavy, or work overhead, and that he often could not pull the starter cord on his lawn mower. He also reported that repetitive use of the elbow made his pain worse but that he could not estimate any additional loss in terms of range of motion. On examination, there was no redness, tenderness, or swelling. Range of motion was reported as flexion to 128 degrees and extension to 0 degrees, with no change after three repetitions. The clinician diagnosed osteochondritis dissecans of the right elbow and found that it would have no effect on the Veteran’s ability to work. The Veteran was afforded a VA examination with regard to heart disabilities that also included findings with regard to his right elbow in January 2011. He reported chronic right elbow pain and that his symptoms were the same throughout the day with no flare up or change with repetitive use. He reported that he did not lift, push, or pull over ten pounds and that he limited his flexion and extension of the right elbow. On examination, the right elbow was not swollen but was slightly tender. There was no crepitus. Range of motion was reported as flexion to 145 degrees, extension to 0 degrees, supination to 85 degrees, and pronation to 80 degrees. Active and passive ranges of motion were equal. There was no additional weakness, fatigability, discoordination, distal restrictive range of motion, or loss of joint function with use or against resistance after three repetitions. The Veteran was afforded a VA examination for elbow and forearm conditions in April 2015. With regard to the functional impact of flare ups and repetition over time, the clinician reported inability to determine whether there were significant additional functional limitations under these circumstances because those circumstances did not currently apply. The United States Court of Appeals for Veterans Claims (Court) has held that there must be an adequate rationale for declining to provide an opinion with regard to the functional impact of flare ups and has specifically found that the rationale that an opinion is not possible without directly observing a flare up is inadequate. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board therefore finds that the April 2015 examination report is inadequate for rating purposes and of no probative value; it will play no role in the Board’s analysis. In his May 2015 substantive appeal (VA Form 9), the Veteran reported that his right elbow has a “reduced range of motion and with swelling and general discomfort” and that this affects his ability to work. He also objected to the April 2015 examination report’s findings regarding pain; as stated above, the Board has found that examination report inadequate and it will play no role in the Board’s analysis. During the March 2018 hearing, the Veteran testified that he was sometimes unable to lift his right elbow due to pain and that stiffness increased if he went too long without moving it. He also testified that he could sometimes lift items that are “a little heavy” one time, but not repetitively. He also testified that his pain was worse on extension than on flexion. The Veteran was afforded an additional VA examination for elbow and forearm conditions in December 2018. With regard to the functional impact of flare ups and repetition over time, the clinician reported inability to determine whether there were significant additional functional limitations under these circumstances because there is “no conceptual or empirical basis for making such a determination without directly observing function under these conditions.” This is the specific rationale the Court rejected as inadequate in Sharp. The Board therefore finds that the December 2018 examination report is inadequate for rating purposes and of no probative value; it will also play no role in the Board’s analysis. The Veteran was afforded an additional VA examination for elbow and forearm conditions in June 2019. The Veteran reported joint pain, swelling, and stiffness. He reported moderate flare ups once or twice a week, lasting one to two days at a time, precipitated by bending, lifting, and exercise. He reported functional impairment in the form of limited range of motion. On examination, range of motion was reported as 0 degrees of extension to 120 degrees of flexion, supination from 0 to 60 degrees, and pronation from 0 to 60 degrees. The range of motion did not itself contribute to functional loss. Pain was noted on flexion, extension, supination, and pronation and it caused functional loss. There was no evidence of pain with weight bearing or objective evidence of localized tenderness, pain on palpation, or crepitus. After three repetitions, range of motion was limited to 0 degrees of extension to 110 degrees of flexion, supination from 0 to 55 degrees, and pronation from 0 to 55 degrees. The clinician found that the examination was medically consistent with the Veteran’s statements regarding repetition over time and that, under those circumstances, pain and lack of endurance would further limit motion to 0 degrees of extension to 100 degrees of flexion, supination from 0 to 50 degrees, and pronation from 0 to 50 degrees. The clinician also found that the examination was medically consistent with the Veteran’s statements regarding flare ups and that, under those circumstances, pain and lack of endurance would further limit motion to 0 degrees of extension to 90 degrees of flexion, supination from 0 to 45 degrees, and pronation from 0 to 45 degrees. There were no additional contributing factors of disability. Muscle strength was normal and there was no muscle atrophy. There was no ankylosis. There was no flail joint impairment, joint fracture, ununited fracture, or malaligned fracture. The clinician found that the Veteran’s right elbow disability would have an impact on his ability to work in the form of elbow pain, stiffness, limited range of motion, and difficulty with heavy lifting or repetitive motion. There was objective evidence of pain on passive range of motion testing and when the joint was used in non-weight bearing. In a June 2019 rating decision, VA granted separate 20 percent ratings for right elbow osteochondritis dissecans and limitation of pronation in right elbow osteochondritis dissecans, effective April 29, 2019, primarily based on the findings of the June 2019 VA examiner. The effective date was based on the date VA received a claim for an increased rating that was redundant because this appeal was still pending. Based on the evidence described above, the Board finds that, affording the Veteran the benefit of the doubt, his right elbow osteochondritis dissecans warrants a rating of 20 percent on and after March 23, 2010. The only VA examination during the period on appeal that described the impact of flare ups and repetition over time in terms of range of motion found that flare ups would cause limitation of flexion to 90 degrees, which warrants a 20 percent rating under Diagnostic Code 5206. For this reason, the Board finds that it is at least as likely as not that the Veteran’s right elbow osteochondritis dissecans has warranted a 20 percent rating throughout the period on appeal. Based on the evidence described above, the Board also finds that, affording the Veteran the benefit of the doubt, his limitation of pronation in right elbow osteochondritis dissecans warrants a rating of 20 percent on and after March 23, 2010. The only VA examination during the period on appeal that described the impact of flare ups and repetition over time in terms of range of motion found that flare ups would cause limitation of pronation to 45 degrees, which warrants a 20 percent rating under Diagnostic Code 5213. For this reason, the Board finds that it is at least as likely as not that the Veteran’s limitation of pronation in right elbow osteochondritis dissecans has warranted a 20 percent rating throughout the period on appeal. The preponderance of the evidence also shows that the Veteran’s right elbow osteochondritis dissecans does not warrant a rating in excess of 20 percent during the period on appeal. The Veteran’s right elbow osteochondritis dissecans was not manifested by ankylosis, limitation of flexion to 70 degrees, limitation of extension to 45 degrees, or impairment of the flail joint, radius, or ulna. In addition, the preponderance of the evidence also shows that the Veteran’s limitation of pronation in right elbow osteochondritis dissecans does not warrant a rating in excess of 20 percent during the period on appeal. The Veteran’s limitation of pronation in right elbow osteochondritis dissecans was not manifested by bone fusion or motion lost beyond the middle of the arc. The Board has considered the Veteran’s lay statements. The Veteran is competent to report his own observations with regard to the symptoms of his right elbow disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). There is nothing in the Veteran’s lay statements that indicates that his functional impairment is equivalent to the criteria for ratings in excess of 20 percent for either of his service-connected right elbow disabilities. In addition, the Board considered whether a higher rating is warranted under the regulations relating to additional functional loss due to pain, weakness, fatigability, incoordination, and other factors under DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45. The evidence of record does not indicate that the Veteran’s functional impairment due to DeLuca factors is equivalent to the criteria for ratings in excess of 20 percent for either of his service-connected right elbow disabilities. Because the Board considered the applicable ratings under every Diagnostic Code pertaining to musculoskeletal disabilities of the elbow, the Board finds that there are no other potentially applicable Diagnostic Codes by which higher ratings can be assigned. 3. Acne Vulgaris of the Chest and Back The Veteran contends that his acne vulgaris of the chest and back warrants a higher rating than that currently assigned. It is currently rated under 38 C.F.R. § 4.118, Diagnostic Code 7828, for acne, with a 10 percent rating on and after October 24, 2000. VA received the Veteran’s claim for an increased rating on March 23, 2010. Diagnostic Code 7828 provides for rating as follows: a 30 percent rating for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck, a 10 percent rating for deep acne affecting less than 40 percent of the face and neck or deep acne other than on the face and neck, and a noncompensable rating for superficial acne (comedones, papules, pustules) of any extent. 38 C.F.R. § 4.118, Diagnostic Code 7828. Diagnostic Code 7828 also provides for rating as disfigurement of the head, face, or neck or scars under the applicable Diagnostic Codes, depending upon the predominant disability. In addition, Diagnostic Code 7829 pertains to chloracne and provides for rating as follows: a 30 percent rating for deep acne affecting 40 percent or more of the face and neck, a 20 percent rating for deep acne affecting the intertriginous areas (the axilla of the arm, the anogenital region, skin folds of the breasts, or between digits), a 10 percent rating for deep acne affecting less than 40 percent of the face and neck or deep acne affecting non-intertriginous areas of the body (other than the face and neck), and a noncompensable rating for superficial acne of any extent. 38 C.F.R. § 4.118, Diagnostic Code 7829. The Veteran was afforded a VA examination for joints disabilities in June 2010 that “also includes skin.” The clinician found that the Veteran’s “face is pretty well spared from this and it is mainly over his thorax and legs.” On examination, there were hyperpigmented acneiform lesions over his front chest and upper back and scattered lesions over his legs, involving 25 percent of his total body surface area and none of his exposed surface area. The clinician diagnosed acne vulgaris and found that it would have no impact on his ability to work. The Veteran was afforded a VA examination for heart disabilities in January 2011 that also addressed his skin symptoms. He reported acne on his chest, back and upper legs and that it did not affect his face at all. He reported some itching associated with his acne. There was no discharge, infection, ulceration, disfigurement, or crusting. On examination, there were no lesions on the face and scalp, multiple areas of slightly hyperpigmented papules on the chest and the back area, and some scattered lesions on his upper thigh area. There was no gross ulceration or cellulitis noted. The clinician diagnosed acne vulgaris and found that it covered 25 percent of the Veteran’s body but none of the exposed areas. In his May 2015 substantive appeal (VA Form 9), the Veteran reported that he had “itching and pustules and it is disfiguring.” During the March 2018 hearing, the Veteran testified that his acne was “all up around [his] neck, down [his] back and [his] chest, [his] stomach, [his] buttocks and now it’s going down [his] leg.” The Veteran was afforded a VA examination for skin diseases in December 2018. The clinician diagnosed acne vulgaris of the chest and back. The Veteran reported intermittent flare ups. On examination, acne vulgaris affected less than five percent of the Veteran’s total body area or exposed area. His acne was on his back and chest, slightly hyperpigmented. Both deep acne and superficial acne were present, but the deep acne did not affect the face or neck. There was no scarring or disfigurement. The clinician found that the Veteran’s acne would have no impact on his ability to work. The Veteran was afforded an additional VA examination for skin diseases in June 2019. The clinician diagnosed acne vulgaris of the chest and back. The Veteran reported that his condition had remained the same. On examination, acne vulgaris affected five to twenty percent of the Veteran’s total body area but none of the exposed area. His acne was on his back and chest, with mild erythema of the follicles. Only superficial acne was present. There was no scarring or disfigurement. The clinician found that the Veteran’s acne would have no impact on his ability to work. The preponderance of the evidence does not show that the Veteran’s service-connected acne vulgaris of the chest and back warrants a rating in excess of 10 percent. The record contains no evidence of deep acne affecting the intertriginous areas or 40 percent or more of the face and neck. No examiner or treatment provider has found that the Veteran’s acne has caused scarring or disfigurement, let alone that scars or disfigurement are the predominant disability. The Board has considered the Veteran’s lay statements. The Veteran is competent to report his own observations with regard to the symptoms of his service-connected acne vulgaris. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Nothing in those statements is inconsistent with the 10 percent rating now assigned. To the extent the Veteran has contended that his skin disabilities cause additional symptoms such as itching, those symptoms are not pertinent to the rating criteria. To the extent that the Veteran has contended that his acne is disfiguring, he is competent to identify disfigurement, but that contention is outweighed by the VA clinicians’ consistent findings that no scars or disfigurement resulting from acne vulgaris exist. Because the Board considered the applicable ratings under every Diagnostic Code pertaining to acne, the Board finds that there are no other potentially applicable Diagnostic Codes by which a higher rating can be assigned. 4. TDIU VA will grant a total disability rating when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from securing and following substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and 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. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the purposes of meeting the requirement of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16 (a). The Veteran’s combined disability rating is 40 percent: his right elbow osteochondritis dissecans is rated 20 percent disabling, his limitation of pronation in right elbow osteochondritis dissecans is rated 20 percent disabling, and his acne vulgaris of the chest and back is rated 10 percent disabling. The criteria for consideration of a schedular TDIU are therefore not met. If a veteran does not meet the applicable percentage standards set forth in 38 C.F.R. § 4.16 (a), the issue of entitlement to a TDIU may be submitted to the Director of the Compensation Service for extraschedular consideration 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); Fanning v. Brown, 4 Vet. App. 225  (1993).  In his March 2010 TDIU claim, the Veteran reported that he last worked full-time in August 2005 and that his occupation at that time was housekeeping. In his March 2010 VA Form 21-8940 (Veterans Application for Increased Compensation Based on Unemployability), he ascribed his unemployability to his right elbow disabilities, acne, and posttraumatic stress disorder (PTSD), but did not explain how these affected his employability. The Veteran is not service-connected for any psychiatric disability. During a September 2004 VA treatment appointment, one year before he stopped working as a housekeeper, the Veteran discussed the occupational impact of his disabilities, but he mentioned low back pain, pain radiating into his arms and legs, numbness and weakness in his right hand and fingers, and fatigue. None of these are service-connected and the Veteran did not report any occupational impact from his right elbow disabilities or his acne vulgaris. The Veteran was afforded a VA joints examination in June 2010 that “also includes skin.” The clinician found that the Veteran’s right elbow and skin disabilities would have no effect on his ability to work and noted that he “had to quit” his job as a housekeeper “because of his back.” The Veteran is not service-connected for any back disability. The Veteran was afforded a VA heart examination in January 2011 that also discussed his right elbow and skin symptoms. The clinician found that the Veteran’s service-connected disabilities would not preclude employment, although his physical activities “would have to be monitored very closely by his primary care provider” due to his nonservice-connected low back disability. In a February 2015 statement, the Veteran reported that his PTSD, which is not service-connected, “contributes to [his] unemployability.” The Veteran was afforded a VA examination for elbow and forearm conditions in April 2015. The clinician found that the Veteran’s service-connected right elbow disabilities would have an impact on his ability to work by causing “[s]ome difficulty lifting more than 20 lbs.” In his May 2015 substantive appeal (VA Form 9), the Veteran reported that his right elbow disability “affects [his] ability to work” due to reduced range of motion, swelling, and general discomfort. During the March 2018 hearing, the Veteran testified that he “had problems when [he] was trying to be a mechanic and everything and so [he] thought [he] used to make a lot of money, but then now they’re saying [he] just can’t hardly make money because [he has] so many problems.” He provided this testimony while discussing issues that are not currently service-connected, such as a psychiatric disability, a right toe disability, and sleep apnea. This was his only statement during the hearing regarding his employability. The Veteran was afforded a VA examination for skin diseases in December 2018. The clinician found that the Veteran’s acne vulgaris would have no impact on his ability to work. The Veteran was afforded an additional VA examination for elbow and forearm conditions in December 2018. The clinician found that the Veteran’s right elbow disabilities would have an impact on his ability to work by causing pain with repeated movements and prolonged tasks. The Veteran was afforded an additional VA examination for elbow and forearm conditions in June 2019. The clinician found that the Veteran’s right elbow disabilities would have an impact on his ability to work in the form of pain, stiffness, limited range of motion, and difficulty with heavy lifting or repetitive motion. The Veteran was afforded an additional VA examination for skin diseases in June 2019. The clinician found that the Veteran’s acne vulgaris would have no impact on his ability to work. The term “substantially gainful occupation” is not defined in the rating schedule. Rather, the Court in Ray v. Wilkie, found the phrase has two components: an economic one and a noneconomic one. 31 Vet. App. 58 (2019). In assessing the Veteran’s ability to secure and follow a substantially gainful occupation, the Board is to consider the Veteran’s history, education, skill, and training as well as physical abilities and mental abilities required by the occupation at issue. Id. The preponderance of the evidence of record shows that the Veteran’s service-connected disabilities, by themselves, have not prevented gainful employment during the period on appeal. No medical professional or counselor has found that the Veteran’s acne vulgaris has any impact on his ability to work and, although the Veteran made a general reference to acne as a partial cause of unemployability in his March 2010 claim, he has not reported any way in which his acne affects his employability. As for the right elbow disabilities, VA examiners have found that their symptoms would cause difficulties for the Veteran with some physical tasks but did not find they precluded him from performing any occupational task. They also would provide no mental health barriers to occupational performance and, as stated above, the Veteran is not service-connected for any psychiatric disability. Additionally, the Veteran has not contended that his right elbow disabilities and acne are sufficient by themselves to preclude employment; he has consistently ascribed his unemployability, at least in part, to disabilities that are not currently service-connected. No medical professional or counselor has found that the Veteran is unemployable only due to his service-connected disabilities. The Board finds that the Veteran’s service-connected disabilities had a significant impact on his employability during the period on appeal (as reflected in his 40 percent overall disability rating) but did not totally preclude gainful employment for which his education and occupational experience would otherwise qualify him. His right elbow disabilities impacted his ability to use his arms, but the evidence also shows that they did not completely preclude any physical activity that would be required during work as a housekeeper, and had no effect on his mental functioning. At his September 2004 VA appointment with occupational medicine, the Veteran reported that he could lift, push, and pull 20 pounds. He also stated that he can dust and sweep. He also stated that he could buff floors so long as another person set up and took down the buffer. These tasks are all consistent with working in the field of housekeeping or similar jobs. The tasks that he stated he could not do were resulting from nonservice-connected conditions. He stated that he could not do prolonged standing or walking, but this was not noted to be because of his right elbow or acne. He also stated that he could not use his right hand or fingers due to numbness and weakness. The manifestations of the Veteran’s right elbow condition are discussed in detail above and they do not include symptoms related to numbness and weakness in the right hand or fingers. He stated that he could not climb ladders or scaffolding due to his lower extremity pain from his back. He stated that he could not work an 8 hour day due to “exhaustion.” The preponderance of the evidence is against the claim for a TDIU and a remand for referral to consider an extraschedular TDIU is therefore not warranted. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ryan Frank, 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.