Citation Nr: 21024969 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 19-01 270 DATE: April 27, 2021 ORDER Entitlement to a rating greater than 10 percent for right ankle strain is denied. Entitlement to a rating greater than 30 percent for dyshidrotic eczema, right foot with recurrent ulcerations, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities from August 18, 2017 is granted. FINDINGS OF FACT 1. The appellant’s service-connected right ankle disability does not at least as likely as not manifest with dorsiflexion limited to less than 5 degrees or plantar flexion limited to less than 10 degrees, even when considering additional range of motion loss after repeated use over time and during flare-ups. 2. The appellant’s service-connected dyshidrotic eczema did not at least as likely as not manifest with symptoms of characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of the exposed areas affected or constant or near-constant systemic therapy. 3. The appellant’s service connected disabilities have a combined rating greater than 70 percent, with at least one disability rated greater than 40 percent disabling, and the appellant at least as likely as not has been unable to obtain or maintain gainful employment due to symptoms of his service-connected disabilities since August 18, 2017, the last day he worked full-time. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a right ankle strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. 2. The criteria for a rating greater than 30 percent for dyshidrotic eczema of the right ankle with recurrent ulcerations have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7806. 3. The criteria for entitlement to TDIU have been met from August 18, 2017. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the United States Army from July 1982 to September 1982 and from February 1986 to August 1989. He also served in the United States Army Reserve. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied increased ratings for a right ankle sprain and for dyshidrotic eczema of the right foot. This decision was appealed in a notice of disagreement (NOD) received by VA in January 2016. A Statement of the Case (SOC) was issued by VA in November 2018. VA received the appellant’s Substantive Appeal (Form 9) in January 2019, perfecting the appeal and requesting a hearing before the Board. In July 2020, the appellant presented sworn testimony at a videoconference hearing with the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the appellant’s claims file. The Board previously remanded these claims in an August 31, 2020 decision. Along with these claims, the Board remanded a claim for service connection for an acquired psychiatric disorder. In a March 2021 rating decision, the RO granted entitlement to service connection for an acquired psychiatric disorder, major depressive disorder, and assigned a 70 percent rating from May 23, 2014. As this was a full grant of that benefit sought on appeal, the issue is no longer within the Board’s jurisdiction. Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of downstream elements such as the disability rating or effective date assigned). A Supplemental Statement of the Case (SSOC) was issued by VA in March 2021 continuing the denial of entitlement to an increased rating for a right ankle sprain and for dyshidrotic eczema of the right foot. Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is based on the veteran’s average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability evaluations is the ability of the body to function under the ordinary conditions of daily life, including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence used to decide whether an [initial] rating on appeal was erroneous. Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of an initial rating, staged ratings may be assigned for separate periods of time based on facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). 1. Entitlement to a rating greater than 10 percent for right ankle strain is denied. The appellant contends that his service-connected right ankle disability has worsened and become more disabling over the previous years. See Appellant’s Hearing Transcript, July 20, 2020. He reports difficulty ambulating, regular use of a cane, decreased range of motion, painful motion, pain on weightbearing, with flare-ups occurring daily with weightbearing. The appellant’s service-connected right ankle strain is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271, for limitation of motion of the ankle. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limited motion of the ankle. A maximum 20 percent rating is warranted for marked limited motion of the ankle. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2020). Normal range of motion of the ankle is 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 38 C.F.R. § 4.71a, Plate II. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992). The Board notes that words such as marked and moderate are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 C.F.R. §§ 4.2, 4.6. VA has amended 38 C.F.R. § 4.71a, Diagnostic Code 5271, with changes taking effect in February 2020. Under the revised Diagnostic Code 5271, a 10 percent rating is warranted for moderate limited motion of the ankle, defined as less than 15 degrees of dorsiflexion or less than 30 degrees of plantar flexion. A maximum 20 percent rating is warranted for moderate limited motion of the ankle, defined as less than 5 degrees of dorsiflexion or less than 10 degrees of plantar flexion. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2021). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the 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.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The appellant underwent VA medical examinations of his ankles in January 2018 and March 2021. At the January 2018 VA examination, the appellant reported flare-ups of increased pain with rainy and cold weather, causing additional functional loss of being unable to walk long distances, being unable to run or play with his grandchildren, trouble bending over and going up and down stairs. Dorsiflexion in the right ankle was measured from 0 to 10 degrees and plantar flexion was measured at 0 to 25 degrees. The examiner opined that based on the appellant’s reports of functional loss, there was no additional range of motion loss during flare-ups or after repeated use over time. The appellant was observed to have normal muscle strength, no signs of muscle atrophy indicating disuse, and no ankylosis, instability, or dislocation of the ankle joint. The examiner did note that the appellant regularly uses a cane to assist in ambulation. Passive range of motion testing caused pain as did non-weightbearing testing. The left ankle was noted as being free from defect with normal range of motion. At the March 2021 VA examination, the appellant reported daily flare-ups of pain that were moderate to severe and were precipitated by walking. X-ray testing showed some minor deterioration of the right ankle joint space, with the beginning signs of arthritis. It was noted that pain increased to the point that it significantly impacted ambulation during flare-ups. Dorsiflexion in the right ankle was measured at 0 to 20 degrees and plantar flexion was measured at 0 to 15 degrees. Measurements were the same in passive range of motion testing. Based on the appellant’s report of symptoms during flare-ups and after repeated use over time, the examiner estimated additional range of motion loss in the ankle, with dorsiflexion of 0 to 15 degrees and plantar flexion of 0 to 10 degrees. The appellant was observed to have normal muscle strength, no signs of muscle atrophy indicating disuse, and no ankylosis, instability, or dislocation of the joint. The examiner did note that the appellant regularly uses a cane to assist in ambulation. Passive range of motion testing caused pain as did non-weightbearing. The left ankle was noted as being free from defect with normal range of motion. The examiner opined additionally that all occupational tasks that require ambulation without assistance, such as walking any distance, or climbing stairs were impacted by this disability. VA treatment records and private treatment records do not show any loss of range of motion greater than that seen on either the January 2018 or March 2021 VA examinations. They do not indicate any signs or symptoms of ankylosis, and do not indicate any malunion or any surgical procedures on the right ankle. Considering all this, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the appellant’s service-connected right ankle disability. An increased rating would require a showing of dorsiflexion limited to less than 5 degrees and plantar flexion limited to less than 10 degrees. Even when accounting for additional range of motion loss during flare-ups and after repeated use over time, and the appellant’s lay reports of symptoms, the appellant’s range of motion lost in the right ankle does not rise to the level necessary to warrant a higher compensable rating under the assigned Diagnostic Code. The Board acknowledges the appellant’s lay reports of symptoms worsening over the prior few years, which is supported by range of motion testing indicating an decrease in range of motion in both dorsiflexion and plantar flexion, especially during a flare-up or after repeated use over time, and the development of some mild degenerative changes seen on x-ray testing. However, this does not rise to a level approximating limitation of dorsiflexion to less than 5 degrees or limitation of plantar flexion less than 10 degrees, which is necessary for establishing “marked” disability under both the previous iteration of Diagnostic Code 5271 as well as under the revised version of Diagnostic Code 5271. The Board has considered whether any other Diagnostic Codes related to disabilities of the ankle would provide for a higher disability rating. However, the appellant had no signs of, and has not asserted that he has experienced, ankylosis in the right ankle, malunion of the os calcis or astragalus, or that he has ever had an astragalectomy. As such, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5272, 5273, and 5274. In conclusion, the Board finds that the preponderance of the evidence is against the appellant’s claim for a rating greater than 10 percent for his service-connected right ankle disability. 38 C.F.R. § 4.71a, Diagnostic Code 5271. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to a rating greater than 30 percent for dyshidrotic eczema, right foot with recurrent ulcerations, is denied. The appellant contends that his service-connected dyshidrotic eczema of the right foot with recurrent ulcerations is more disabling than currently rated because it contributes to him being unable to obtain or maintain gainful employment as a result of its impact on his ability to walk. He asserts that his dyshidrotic eczema manifests with symptoms of blisters and ulcers on his feet if he has to spend too much time on his feet. He indicated that he spends about ninety percent of his time staying off his feet. See Hearing Transcript, July 20, 2020. His VA examinations and medical treatment records show that this service-connected disability causes an antalgic gait and that the appellant regularly uses a cane for ambulation as a result. The appellant asserts that his right foot disability, along with his other service-connected disabilities, causes him to be unable to obtain or maintain gainful employment. This contention has been considered separately below. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that a claim for TDIU, either expressly raised by the appellant or raised by the record, is not a separate “claim” for benefits, but rather, is part and parcel of the claim for an increased rating) The appellant’s current dyshidrotic eczema of the right foot with recurrent ulcerations is assigned a 30 percent rating under Diagnostic Code 7806. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or the disability may be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran’s skin condition; and (2) whether the given treatment is “like” a corticosteroid or other immunosuppressive drug.” Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or, the disability may also be rated as disfigurement of the head, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824. Here, the evidence of record demonstrates that the predominant disability is dyshidrotic eczema affecting the foot rather than scarring of the feet. During the period on appeal, the disability has manifested with symptoms consisting of lesions of the skin and ulcers affecting less than 20 percent of total body area and less than 20 percent of total exposed body area. Ulcers have required treatment with corticosteroids or other immunosuppressive drugs for 6 or more weeks, but not constantly or near constantly during the period on appeal. Treatment typically occurred when the appellant experienced a flare-up of his condition. Additionally, in 2020, the appellant began receiving gamma x-ray therapy to treat his service-connected disability, which occurred for less than 6 weeks. Prolonged walking or standing causes flare-ups of the condition, resulting in ulcers which limit ambulation and require the regular use of a cane. See VA Compensation and Pension Examination, March 2, 2021 and VA Compensation and Pension Examination, January 15, 2015. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent under the pre-August 13, 2018, regulations because the appellant’s disability does not more nearly approximate more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. As noted above, the appellant’s treatment with corticosteroids or other immunosuppressive drugs is episodic through the year when he experiences a flare-up of symptoms and does not occur on a constant or near constant basis. Additionally, symptoms of his service-connected eczema only manifest on his right foot, and do not affect other parts of his body. His right foot does not make up more than 40 percent of his total body area or his total exposed body area. Additionally, for the same reasons, the Board finds that the preponderance of the evidence is also against the assignment of a rating in excess of 30 percent under the August 13, 2018, regulations because the appellant’s disability does not more nearly approximate characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy required over the past 12-month period. The Board acknowledges that the appellant believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the appellant is competent to report observable symptoms, to include the development of lesions on his right foot, and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and medical treatment records do not show, that the appellant’s disability more nearly approximates the criteria in the next higher rating under either the pre-August 2018 rating criteria or under the post-August 2018 rating criteria. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. In conclusion, the Board finds that the preponderance of the evidence is against the appellant’s claim of a rating in excess of 30 percent for service-connected dyshidrotic eczema of the right foot with recurrent ulcerations. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities from August 18, 2017 is granted. As an initial matter, the Board notes that the issue of entitlement to TDIU has been raised by the appellant in direct relation to his claims for an increased rating. The appellant contends that he has been unable to work due to his service-connected dyshidrotic eczema, along with his other service-connected disabilities to include his right ankle disability, his knee disabilities, and his mental health disability He asserts that these all cause pain, impairment in ambulation, and mental health symptoms which contribute primarily to his inability to work. See Appellant’s Hearing Transcript, July 20, 2020; see also Appellant’s Statement in Support of Claim, May 29, 2019. As such, the Board finds that entitlement to TDIU is on appeal as part of the claims for an increased rating for dyshidrotic eczema and for a right ankle disability. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that a claim for TDIU, either expressly raised by the appellant or raised by the record, is not a separate “claim” for benefits, but rather, is part and parcel of the claim for an increased rating). Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). An evaluation of the level of disability must include consideration of functional impairment of the ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. A total disability rating for compensation purposes may be assigned where the schedular rating is less than total, where it is found that the disabled person is unable to secure and follow a substantially gainful occupation as a result of a service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, providing 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. 38 C.F.R. §§ 3.340, 4.16(a). Nevertheless, 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 disability shall be rated totally disabled. Thus, where the schedular threshold of 38 C.F.R. § 4.16(a) is not met, an extraschedular rating may be warranted under 38 C.F.R. § 4.16(b). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment. See 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability”. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term “unemployability” is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion. Individual unemployability, however, must be determined without regard to any nonservice-connected disabilities or advancing age. 38 C.F.R. §§ 3.341(a), 4.16, 4.19. The ultimate question is whether a veteran, in light of their service-connected disabilities, is capable of performing the physical and mental acts required by employment, not whether they can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The appellant’s total disability rating during the period on appeal is 90 percent, with at least a single disability rated 40 percent disabling. As such, the Board finds that the schedular criteria for TDIU are met. 38 C.F.R. § 4.16(a). As such, the question the Board must consider is whether the appellant’s service-connected disabilities, cause him to be unable to obtain or maintain gainful employment. After a review of the evidence of record, the Board finds that the appellant’s service-connected disabilities of the lower extremities prevent him from obtaining or maintaining gainful employment in fields that require any amount of regular walking or standing, as these disabilities severely affect his ambulation. Simple and essential actions to many occupations, such as walking and standing, both cause exacerbations of his service-connected dyshidrotic eczema and require the use of a cane. The Board also finds that the appellant’s service-connected Major Depressive Disorder manifests with a constellation of symptoms that prevents him from obtaining or maintaining gainful employment in fields that require concentration, focus, and building relationships, all of which were essential skills in his career as a financial planner. Symptoms of the appellant’s Major Depressive Disorder, such as depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, disturbance of mood or motivation, and difficulty in adapting to stressful circumstances such as work or a work like setting all combine to affect the appellant’s ability to do both the occupation he participated in for over twenty years, as well as most types of work in an office-type setting. Considering this, the Board finds that the combination of manifested symptoms of the appellant’s service-connected disabilities prevent him from obtaining or maintaining any gainful employment. The claims folder indicates the appellant worked for many years as a financial planner, but ceased doing this kind of work on August 18, 2017 due to symptoms related to his mental health disability and his use of narcotic medication to deal with symptoms of pain caused by his service-connected lower extremity disabilities. In an August 2020 decision, the Social Security Administration found the appellant was totally disabled and unable to work from August 18, 2017. Nonservice-connected diabetes mellitus, type II and its various secondary manifestations were considered in this decision along with the currently service-connected psychiatric disorder. It does not appear the appellant’s other service-connected lower extremity disabilities, to include both knees, his right ankle, and his eczema of the right foot were considered. Symptoms related to the appellant’s service-connected right ankle disability, to include painful motion, loss of range of motion, and difficulty ambulating, and symptoms related to the appellant’s service-connected eczema of the right foot, recurring ulcers that flare-up with prolonged walking or standing and gait disturbance are discussed above. The appellant’s service-connected knee disabilities present with painful motion and loss of range of motion in flexion. The appellant’s service connected acquired psychiatric disability manifests with symptoms that cause occupational and social impairment in most areas such as depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, and difficulty adapting to stressful circumstances such as work or a work like setting The appellant’s personal testimony at his July 2020 Board hearing indicated that the complications of his service-connected eczema of the right foot greatly affect his occupational capacity. He indicated he had to spend ninety percent of his time off his feet to avoid developing the recurring ulcers and blisters on his feet that then prevent him from walking. This impacts his ability to do work requiring being on his feet. Additionally, he testified that pain resulting from these disabilities of the lower extremities required the use of narcotic medication, morphine, for control. This use of prescription narcotic medication severely impacts the appellant’s ability to commute to and from a work place, and his ability to perform complex or sensitive tasks, particularly in his chosen profession of financial planning. He also testified about the impacts of his mental health disability, which was granted entitlement to service connection subsequent to the hearing and assigned a 70 percent rating for the entire period on appeal. In describing his symptoms, the appellant re-iterated what he had already suggested in his written statements to VA, that his mental health symptoms caused significant impact on his ability to function in the workplace. Considering all this, the Board finds that the evidence of record establishes the appellant is at least as likely as not unable to follow or obtain a substantially gainful occupation due to service-connected disabilities from August 18, 2017. As the evidence is at least in equipoise, the Board grants the appellant the benefit of the doubt and concludes that the criteria for entitlement to TDIU are met from August 18, 2017. 38 C.F.R. §§ 4.3, 4.16(a). Prior to that day, the preponderance of the evidence is against the assignment of a TDIU as the appellant was shown to have been engaged in substantially gainful employment. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Kleponis, 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.