Citation Nr: 21023223 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 16-28 572 DATE: April 20, 2021 ORDER Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to February 25, 2019 is denied. An increased rating of 70 percent, but no higher, for PTSD from February 25, 2019 is granted. Entitlement to a compensable rating for hypertension is denied. Entitlement to a rating in excess of 20 percent for left (non-dominant) shoulder acromioclavicular joint separation with shoulder strain and labral tear is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to a combination of service-connected disabilities is granted from June 21, 2014, but no earlier. FINDINGS OF FACT 1. Prior to February 25, 2019, the Veteran’s PTSD has not been manifested by symptoms that have resulted in occupational and social impairment with deficiencies in most areas or total occupational and social impairment. 2. As of February 25, 2019, it is reasonably shown that the Veteran's PTSD has been manifested by symptoms that have resulted in occupational and social impairment with deficiencies in most areas; total occupational and social impairment has not been shown. 3. During the appeal period, the Veteran’s hypertension did not manifest in diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more. Also, the Veteran did not both have a history of diastolic pressure predominantly 100 or more and require continuous medication for control. 4. The Veteran’s left (non-dominant) shoulder acromioclavicular joint separation with shoulder strain and labral tear is not manifested by limitation of motion of the arm to 25 degrees from side of flexion and/or abduction limited to 25 degrees from side. 5. From June 21, 2014, but no earlier, it is reasonably shown that the Veteran’s service-connected disabilities have precluded him from obtaining or maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. Prior to February 25, 2019, the criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. Beginning February 25, 2019, the criteria for a 70 percent rating, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code (Code) 9411. 3. The criteria for a compensable rating for service-connected hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.31, 4.104, Diagnostic Code 7101. 4. The criteria for a rating in excess of 20 percent for left (non-dominant) shoulder acromioclavicular joint separation with shoulder strain and labral tear have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201-5202, effective February 7, 2021 Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5201-5202). 5. From June 21, 2014, but no earlier, the criteria for a TDIU rating based on service-connected disabilities have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1992 to February 2013. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a July 2013 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was previously before the Board. In February 2019, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. An August 2019 Board decision remanded the claim for additional development. Increased Rating Disability ratings are determined by comparing a Veteran’s symptomatology during the pertinent period on appeal with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. An exception to this rule applies when the rating criteria are successive. In such a case, all the requirements of the lower levels must be met before a higher level is awarded, and 38 C.F.R. §§ 4.7 and 4.21 do not apply. Johnson v. Wilkie, 30 Vet. App. 245 (2018). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Lay evidence may be competent to address any matter not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises or statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). The Board has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence pertinent to the issue on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all contents of the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran’s disabilities prior to the rating period on appeal to see if the history supports a higher rating during the rating period on appeal. 1. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder A June 2013 rating decision on appeal awarded service connection for posttraumatic stress disorder (PTSD) and assigned a 50 percent evaluation. The Veteran has requested an increase in the assigned disability rating. According to 38 C.F.R. § 4.130, Code 9411, a 50 percent evaluation is warranted for PTSD where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; and memory loss for names of close relatives, own occupation, or own name. The specified factors for each incremental psychiatric rating are not requirements for a particular rating, but instead are examples providing guidance as to the type and severity of symptoms’ effects on social and work situations. Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Although certain symptoms must be present in order to establish the diagnosis of PTSD, as with other conditions, it is not the symptoms but their effects that determine the level of impairment. Id.: see also Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (explaining that the symptoms that could give rise to a given rating are those in like kind, i.e., of similar duration, severity, and frequency, to those provided in the non-exhaustive lists). Global Assessment of Functioning (GAF) scores were used in the past under DSM-IV to assist in assessing severity level. However, GAF scores have been found to be unreliable and not sufficient evidence for rating a psychiatric disorder. See Golden v. Shulkin, 29 Vet. App. 221 (2018). The April 2014 VA examiner opined the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Veteran reported that he had been married to his second wife for nearly two years and that the marriage had been on and off due to his mood changes and anger. He also stated that his three children do not enjoy spending time with him due to his behavior, attitude, and anger. He had five friends from high school. The Veteran was looking for work because he left his position at the postal service after six months. He reported that he did not enjoy the position because of confrontations at work. The February 2015 VA examiner opined the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran reported he was last employed in June 2014. The VA examiner noted markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, irritable behavior and angry outbursts typically expressed as verbal or physical aggression, and problems with concentration. The Veteran was alert and oriented, adequately groomed, showed good concentration, was calm, made good eye contact, and had fluent speech. The Veteran denied current thoughts of suicide or homicide. The December 2017 VA examiner opined the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran reported being married for five years and having many friends. He was attending school, playing soccer, playing volleyball, and canoeing. The Veteran reported he had been unemployed since June 2014. The active symptoms were noted to be depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The Veteran denied any self-harm but was in a physical altercation a few months prior. At the February 25, 2019 hearing, the Veteran testified his PTSD had gotten worse because it affects his daily life, job, kids, and soon to be ex-wife. He stated the last time he was employed was June 2014 when he was released of his duties due to continued absences due to PTSD episodes or appointments. The Veteran also testified that his nightmares had increased. He testified that he had been applying for jobs. When he gets hired, he does not show up because he is afraid to even go and mess up his record or go off on somebody. The Veteran also stated that his child did not want to be around him. In June 2019, the Veteran underwent a psychiatry initial evaluation at Palatka VA Clinic. The Veteran reported worse depressed mood, sadness, feelings of guilt, decreased energy, and difficulty with concentration and focusing attention. There was no nihilistic thinking. He was amotivational. No suicidal ideation. The Veteran’s social and work functioning were found to be impaired by his symptoms. At an August 2019 psychological consultation, the Veteran denied previous suicidal ideation, plan, or intent. The January 2020 VA examiner opined the Veteran has occupational and social impairment with reduced reliability and productivity. The Veteran was noted to have the symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work like setting. The Veteran was cooperative, oriented to person, place, time and situation, no abnormal motor movements, no evidence of psychosis, paranoia, or mania, normal speech, and good personal hygiene. The Veteran reported the additional symptoms of struggle with re-experiencing (nightmares), social withdrawal, hyper-vigilance, feelings of detachment, insomnia, exaggerated startle response, irritability, and avoidance of reminders. Upon review of the evidence of record the Board finds that prior to February 25, 2019 the Veteran’s symptoms produced no more than occupational and social impairment with reduced reliability and productivity. While the Veteran reported being unemployed and having a recent physical altercation, he also reported being married for five years, having many friends, attending school, and playing on sports teams. Additionally, the December 2017 VA examiner opined the Veteran has occupational and social impairment with reduced reliability and productivity. As the functional impairments due to PTSD does not more nearly approximate the schedular criteria for a 70 percent rating under Code 9411, the Board finds that a rating in excess of 50 percent is not warranted prior to February 25, 2019. 38 C.F.R. § 4.7. After resolving the benefit of the doubt in favor of the Veteran, the Board finds that his psychiatric symptoms have produced occupational and social impairment with deficiencies in most areas beginning February 25, 2019. At the Board hearing on February 25, 2019, the Veteran reported his PTSD had gotten worse. In addition to not working, he was separated from his wife and planning to divorce, and his child did not want to be around him. The June 2019 treatment provider opined the Veteran had impaired occupational and social functioning. While the January 2020 VA examiner opined the Veteran has occupational and social impairment with reduced reliability and productivity, equivalent to a 50 percent disability rating, the exam showed difficulty in adapting to stressful circumstances (including work or a worklike setting) and inability to establish and maintain effective relationships, both of which are criteria listed in the 70 percent rating. He had mild memory loss and nightmares causing sleep disturbance. The Board finds no reason to question the credibility of the accounts of the Veteran; they are consistent with reports by his treating mental health personnel and VA examiners. As the functional impairments due to PTSD meets (or at least approximates) the schedular criteria for a 70 percent rating under Code 9411, the Board finds that such rating is warranted beginning February 25, 2019. 38 C.F.R. § 4.7. A rating in excess of 70 percent, however, is not warranted. The evidence of record does not support a finding that the Veteran’s impairment due to his PTSD more nearly approximates total occupational and social impairment, and a 100 percent rating must be denied. In particular, the Board does not find that the Veteran’s nightmares and mild memory loss are of similar frequency, severity, or duration to the symptoms listed in the 100 percent criteria. For example, the symptoms do not equate to the severity of the cognitive impairment manifested by the criteria of memory loss for names of close relatives, own occupation, or name noted in the 100 percent criteria. Notably, the Veteran denied current or prior suicidal ideation. As explained above, the Board has found that that the evidence of record shows that as of February 25, 2019, the Veteran has manifested sufficient symptoms of the type and extent, frequency, or severity (as appropriate) to result in the occupational and social impairment with deficiencies in most areas required for the next higher of 70 percent. 38 C.F.R. § 4.130. However, he did not show symptoms of the type and extent, frequency, or severity (as appropriate) to result in total occupational and social impairment required for the next higher of 100 percent. Id. Moreover, the Veteran had some social interactions and relationships, reflecting that his overall level of impairment did not more nearly approximate total occupational and social impairment. 1. Entitlement to a compensable rating for hypertension In the instant appeal, the Veteran seeks entitlement to an initial compensable evaluation for his hypertension disability. The Veteran was initially awarded entitlement to service connection for hypertension, effective February 26, 2013, and assigned a non-compensable evaluation under Diagnostic Code (DC) 7101. Under DC 7101, a 10 percent rating for diastolic pressure predominantly 100 or more, or; systolic pressure of 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. 38 C.F.R. § 4.104, Diagnostic Code 7101. The criteria for a 10 percent rating are disjunctive. See Johnson v. Brown, 7 Vet. App. 9 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). The Board notes that the plain language of DC 7101 contemplates the effects of medication. See McCarroll v. McDonald, 28 Vet. App. 267, 273 (2016). A higher, 20 percent rating is assigned when diastolic pressure is predominantly 110 or more, or; systolic pressure is predominantly 200 or more. A 40 percent rating requires diastolic pressure of predominantly 120 or more. A 60 percent disability requires diastolic pressure of predominantly 130 or more. 38 C.F.R. § 4.104, DC 7101. The Board notes that the 10 percent rating criteria requires evaluation of blood pressure readings from different time periods. If either diastolic or systolic pressure predominantly above the stated values (100 or 160, respectively) is shown during the period on appeal, a 10 percent rating is also appropriate. Alternatively, if a veteran's condition requires continuous medication and he has a history of diastolic pressure predominantly 100 or more, a 10 percent rating is appropriate. The medical records associated with the Veteran's claims file contain more than fifteen blood pressure readings during the period on appeal. Of those, every reading had a diastolic pressure below 100, and every reading had a systolic pressure below 160. A VA examiner stated in January 2020 that the Veteran’s hypertension is idiopathic in nature, mild in extent and severity, not causing any further damage to the body, being caught and treated when symptoms first arose and is well controlled with medication. The Veteran testified that one month prior to the February 2019 hearing, a private treatment provider measured his blood pressure at 199 over “one something.” The RO requested information about the private provider, but the Veteran did not respond. The Veteran's medical records do show that his hypertension has required continuous medication since before the period on appeal. However, the evidence of record shows the Veteran had no history of diastolic pressure predominantly 100 or more. Based on the above information, the Board finds that the Veteran does not have a history of diastolic pressure predominantly 100 or more. Because the Veteran does not both require continuous medication to control his hypertension and have a history of diastolic pressure predominantly 100 or more, he does not meet the criteria for a 10 percent rating on that basis. Because the remaining rating criteria is progressive, he cannot meet the criteria for a rating higher than 10 percent. For these reasons, the Board finds that an initial compensable disability rating is not warranted for the Veteran's service-connected hypertension. 2. Entitlement to a rating in excess of 20 percent for left (non-dominant) shoulder acromioclavicular joint separation with shoulder strain and labral tear A June 2013 rating decision granted service connection for left (non-dominant) shoulder acromioclavicular joint separation with shoulder strain and labral tear, rated 10 percent from February 26, 2013 under 38 C.F.R. § § 4.71a, Code 5201. A March 2018 rating decision assigned a 20 percent evaluation as of November 14, 2017. A subsequent August 2020 rating decision granted an earlier effective date of February 26, 2013 for the 20 percent rating for left (non-dominant) shoulder acromioclavicular joint separation, recharacterized the left shoulder disability as including shoulder strain and labral tear, and rated the Veteran’s shoulder under DC 5201-5202. For rating purposes, a distinction is made between major (dominant) and minor musculoskeletal groups. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. 38 C.F.R. § § 4.69. The Veteran is right-hand dominant; thus, his service-connected left shoulder disability involved his minor extremity. Shoulder disabilities are rated under Codes 5200 to 5203. 38 C.F.R. § § 4.71a. As of February 7, 2021, the musculoskeletal rating criteria were revised and the version more favorable to the Veteran applied; however, application of the amended regulations do not warrant a higher rating. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5200-5203) Code 5200 contains the criteria for rating ankylosis of scapulohumeral articulation (the scapula and humerus move as one). 38 C.F.R. § § 4.71a. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5200-5203) Under DC 5201, for limitation of motion of the minor shoulder and arm, a 20 percent rating is warranted when range of motion is limited at shoulder level or to midway between side and shoulder level and a 30 percent rating is assigned when range of motion of the arm is limited to 25 degrees from the side. Under the revised criteria, for limitation of motion of the minor shoulder and arm, a 20 percent rating is warranted when range of motion is limited at shoulder level (flexion and /or abduction limited to 90 degrees) or to midway between side and shoulder level (flexion and /or abduction limited to 90 degrees) and a 30 percent rating is assigned when range of motion of the arm flexion and/or abduction is limited to 25 degrees from the side Id. Under DC 5202, for other impairment of the humerus for the minor shoulder and arm, malunion (marked or moderate deformity) warrants a 20 percent rating, recurrent dislocation is rated at 20 percent; and fibrous union of the humerus is rated at 40 percent; nonunion of the humerus is rated 50 percent; and a loss of the humerus head is rated at 70 percent. Id. Under DC 5203, for impairment of the clavicle or scapula of the minor shoulder and arm, malunion or nonunion without loose movement warrant a 10 percent rating, nonunion with loose movement or dislocation warrant a maximum rating of 20 percent. Id. Normal range of motion of the shoulder is set forth in 38 C.F.R. § § 4.71, Plate I. Normal forward elevation, or flexion, is from 0 to 180 degrees. Normal shoulder abduction is also from 0 to 180 degrees. Normal external rotation and internal rotation are from 0 to 90 degrees. 38 C.F.R. § § 4.71, Plate I. Initially, the Board notes that applicability of Code 5200 and 5203 have been considered. However, as ankylosis is not shown, a rating in excess of 30 percent is not warranted under Code 5200 and 20 percent is the maximum rating permitted under Code 5203 and the examiner noted humerus condition affects range of motion, which is already considered in the 20 percent presently assigned under Codes 5201-5202. Assigning a separate rating under 5203 for limitation of motion would constitute pyramiding. Therefore, the Board finds that these Codes do not have applicability in this matter. 38 C.F.R. § § 4.71a, Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5200-5203). As noted above, 38 C.F.R. § 4.59 allows for consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint, and the current 20 percent rating takes into account painful motion. However, the examination reports and treatment records do not demonstrate (and the Veteran does not assert) that there is limited motion of the arm to 25 degrees from side so as to warrant the next higher 30 percent rating for the minor arm. At the December 2017 VA examination, the Veteran reported left shoulder pain beginning in 2010 and since then has worked out exercising and lifting weights to try to stabilize the shoulder and decrease his pain. The Veteran reported he has never had a dislocation of the shoulder and has not had any surgery. The VA examiner noted abnormal range of motion. Flexion was 0 to 140 degrees, abduction 0 to 120 degrees, external rotation 0 to 90 degrees, and internal rotation 0 to 90 degrees. All ranges of motion exhibited pain. The Veteran was able to perform repetitive use testing. No ankylosis was noted. Dislocation of the clavicle or scapula was suspected but did not affect range of motion of the shoulder. The Veteran did not have conditions or impairments of the humerus. The examiner did not offer an opinion on additional functional limitations during flare-ups because the Veteran was not having a flare-up during the examination. The January 2020 VA examination showed abnormal range of motion of the left shoulder with flexion of 0 to 90 degrees, abduction 0 to 90 degrees, external rotation 0 to 70 degrees, and internal rotation of 0 to 80 degrees. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. The Veteran reported flare ups of the left shoulder occur with heavy lifting and are alleviated by rest and pain medications. While the examination was not performed during a flare up, the examiner assessed the Veteran’s range of motion during a flare up as range of motion of the left shoulder with flexion of 0 to 80 degrees, abduction 0 to 80 degrees, external rotation 0 to 70 degrees, and internal rotation of 0 to 70 degrees. No ankylosis was noted. A clavicle, scapula, acromioclavicular joint or sternoclavicular joint condition was suspected. The VA examiner checked dislocation of the left shoulder. The clavicle or scapula condition was found to affect range of motion of the shoulder. The Veteran was found to have moderate deformity of the humerus that affected range of motion of the shoulder. Considering the evidence of record, the Board finds that the Veteran's left shoulder disability approximates a 20 percent rating under DC 5201-5202, but no higher. The record does not contain limitation of motion to 25 degrees, flexion and/or abduction limited to 25 degrees from side, or fibrous union of the humerus. As such, an increased rating above 20 percent for his left shoulder disability is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Entitlement to individual unemployability (TDIU) Where the schedular rating is less than total, a TDIU may be assigned when it is found that a veteran is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16 (a). In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Board notes that during the appeal period the Veteran was service connected for sleep apnea, PTSD, dry eye syndrome, diabetes mellitus type II, left (non-dominant) shoulder acromioclavicular joint separation with shoulder strain and labral tear, left patellofemoral syndrome, thoracolumbar spondylosis with degenerative arthritis of the spine, left (non-dominant) trapezial metacarpal osteoarthritis, right (dominant) trapezial metacarpal osteoarthritis, bilateral pes planus, left hallux valgus, right hallux valgus, hypertension, erectile dysfunction, scar nose residual laceration, irritation fibroma, eczema knuckles of both hands, tinea cruris groin area, and tinea pedis between toes of both feet. Two of the service-connected disabilities were rated at 40 percent or above. The Veteran was in receipt of a 50 percent disability rating for sleep apnea from February 26, 2013, a 50 percent disability rating for PTSD from February 26, 2013, which was increased to a 70 percent disability rating from February 25, 2019. From February 26, 2013, the Veteran’s combined evaluation for compensation was 90 percent. See Rating Decision Codesheet, dated August 2020. Throughout the appeal period, the Veteran did have an individual disability ratable at 40 percent or more and his combined disability evaluation was above 70 percent. Accordingly, the schedular criteria for TDIU were met based on a combination of the service-connected disabilities. See 38 C.F.R. § 4.16 (a). The Board finds, for the following reasons, entitlement to a TDIU based on a combination of the Veteran’s service-connected disabilities is granted from June 21, 2014, but no earlier. Prior to June 21, 2014, the Veteran was employed, so entitlement to TDIU is not warranted. He reported on his June 2014 VA Form 21-8940, Veteran’s Application for Increased Compensation Based Upon Unemployability, that he worked full time through June 20, 2014 and that he earned $3,000 per month working for a government agency. From June 21, 2014, the combination of the functional impairment from his service-connected disabilities at least as likely as not caused the veteran to be unable to secure or follow a substantially gainful occupation. Treatment notes show the Veteran was working at a sugar cane plantation in December 2019 and part-time in cornfields in Georgia and Indiana in August 2020. This short term and part-time work is not evidence of substantial gainful employment. However, the record does not support a finding that a finding of TDIU is warranted for any service-connected disability alone at any time during the appeal. In June 2014, the Veteran did not report that a single disability resulted in TDIU but instead reported that his PTSD and sleep apnea both prevented him from securing or following any substantial gainful occupation. See Veteran’s Application for Increased Compensation Based on Unemployability. The Veteran remarked that he was let go from his job because he had many days off and not enough leave to cover them. However, the Veteran testified years later at the February 2019 hearing that he is unemployed due to his PTSD. Prior to February 26, 2019, the Veteran’s PTSD was not manifested by symptoms that have resulted in occupational and social impairment with deficiencies in most areas or total occupational and social impairment. The Board also finds that during this period there is no plausible evidence that the Veteran was unable to secure or follow a substantially gainful occupation as a result of PTSD alone. Prior to February 26, 2019, PTSD symptoms produced no more than occupational and social impairment with reduced reliability and productivity according to VA examiners. While the Veteran reported being unemployed and having a recent physical altercation, he also reported being married for five years, having many friends, attending school, and playing on sports teams. For the reasons discussed above, the Veteran’s PTSD is now rated 70 percent disabling beginning February 25, 2019. Thus, the minimum threshold schedular rating requirement for a TDIU rating under 38 C.F.R. § 4.16 (a) has been met from February 25, 2019. The question remaining is whether the Veteran’s service-connected PTSD (alone) has rendered him incapable of participating in a substantially gainful occupation from this date. The evidence does not show that the Veteran is entitled to TDIU based on PTSD alone during this period. At the February 2019 hearing the Veteran testified he gets hired for jobs but does not show up because he is afraid to go and mess up his record. During this period, the Veteran was able to take classes. Therefore, TDIU based on PTSD alone is not warranted. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Sowden, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.