Citation Nr: 21040515 Decision Date: 07/05/21 Archive Date: 07/05/21 DOCKET NO. 16-26 680 DATE: July 5, 2021 ORDER Entitlement to an initial rating in excess of 10 percent prior to April 26, 2016, and in excess of 20 percent thereafter for osteopenia of the lumbar spine is denied. Entitlement to an initial 10 percent rating prior to April 26, 2016, for osteopenia of the left hip is granted. Entitlement to an initial rating in excess of 10 percent beginning April 26, 2016, for osteopenia of the left hip is denied. Entitlement to an initial 10 percent rating prior to April 26, 2016, for osteopenia of the right hip is granted. Entitlement to an initial rating in excess of 10 percent beginning April 26, 2016, for osteopenia of the right hip is denied. Entitlement to a total disability rating based on individual unemployability (TDIU), prior to October 22, 2015 (effective October 19, 2010), is granted. FINDINGS OF FACT 1. Prior to April 26, 2016, the Veteran's osteopenia of the lumbar spine manifested as no more than painful motion. 2. From April 26, 2016, the evidence shows flexion in the Veteran's back greater than 30 degrees, and there is no evidence of ankylosis or associated neurologic abnormalities. 3. Prior to April 26, 2016, the range of motion in the Veteran's left and right hips was without pain and was characterized as flexion to 125 degrees, extension to 30 degrees, abduction to 45 degrees, adduction to 25 degrees, internal rotation to 40 degrees, and external rotation to 60 degrees. The Veteran, however, complained of episodes of pain while walking. 4. From April 26, 2016, the Veteran has painful and limited range of motion in his left hip and right hip but there is no evidence of ankylosis and, at worst, flexion was limited to 80 degrees, extension was 5 degrees or greater, and abduction was not lost beyond 10 degrees. 5. Prior to October 22, 2015, the evidence of record demonstrates the Veteran was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 10 percent prior to April 26, 2016, and in excess of 20 percent thereafter for osteopenia of the lumbar spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 2. The criteria for entitlement to an initial 10 percent rating prior to April 26, 2016, for osteopenia of the left hip have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5002, 5250, 5251, 5252, 5253. 3. The criteria for entitlement to an initial rating in excess of 10 percent beginning April 26, 2016, for osteopenia of the left hip have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5002, 5250, 5251, 5252, 5253. 4. The criteria for entitlement to an initial 10 percent rating prior to April 26, 2016, for osteopenia of the right hip have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5002, 5250, 5251, 5252, 5253. 5. The criteria for entitlement to an initial rating in excess of 10 percent beginning April 26, 2016, for osteopenia of the right hip have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5002, 5250, 5251, 5252, 5253. 6. Prior to October 22, 2015 (effective October 19, 2010), the criteria for entitlement to a TDIU are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1974 to August 1975. These matters are before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This rating decision granted service connection for the lumbar spine, left hip and right. A 10 percent rating was assigned for the lumbar spine and noncompensable ratings were assigned for the left and right hips, all effective October 19, 2010. Thereafter, an RO rating decision in May 2016 increased the osteopenia rating of the lumbar spine to 20 percent, effective April 26, 2016. In addition, the left and right hip osteopenia was increased to 10 percent, also effective April 26, 2016. On a claim for an increased rating, the claimant will generally be presumed to be seeking the maximum benefit allowed by the law and regulation, and it follows that such claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6Vet. App.35, 38 (1993). Therefore, the issues have been recharacterized as shown on the title page. In a July 2018 rating decision, the Veteran was granted entitlement to a TDIU, effective October 22, 2015. As a TDIU claim has been raised by the record during the pendency of the appeal for an increased rating associated with the lumbar spine and bilateral hip disabilities, it is considered part and parcel to his increased rating claim. Rice v. Shinseki, 22 Vet. App. 447 (2009). As a TDIU was not granted for the entire period on appeal, the RO's decision resulted in only a partial grant of benefits. Therefore, the Veteran's claim for entitlement to a TDIU remains on appeal. Harper v. Wilkie, 30 Vet. App. 356, 359 (2018). In October 2018, the Board remanded the appeal to the RO for additional development. The appeal has been returned to the Board for further consideration. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In determining the propriety of the initial rating assigned after a grant of service connection, the evidence since the effective date of the grant of service connection must be evaluated and staged ratings must be considered. Fenderson v. Brown, 12 Vet. App. 119, 126-127 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Fenderson, 12 Vet. App. at 126-127; Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. 1. Entitlement to an initial rating in excess of 10 percent prior to April 26, 2016, and in excess of 20 percent thereafter for osteopenia of the lumbar spine The Veteran contends that he is entitled to a higher rating for his back disability. The Veteran's back disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5237. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. 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 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."). 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). Notably, there was a regulation change to musculoskeletal ratings effective February 7, 2021. However, the regulations that pertain to the back have, as is relevant here, not changed. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent prior to April 26, 2016, and in excess of 20 percent from April 26, 2016, for the back disability. Prior to April 26, 2016, the evidence shows painful motion but does not show forward flexion of the thoracolumbar spine less than 60 degrees, combined range of motion less than 120 degrees, or muscle spasm or guarding resulting in an abnormal gait or abnormal spinal contour. During the January 2011 VA examination, the Veteran reported pain and fatigue without limitation of motion. The examiner recorded flexion to 90 degrees with pain at the end point and extension to 30 degrees without pain. From April 26, 2016, the evidence does not show forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. During the April 2016 VA examination, the Veteran reported experiencing flare-ups in symptoms described as occasional lower back pain. The examiner initially recorded flexion to 60 degrees. There was no loss of function or range of motion after repetitive use testing. The examiner did not observe pain on examination or with weight-bearing. The examiner found no evidence of ankylosis and no use of assistive devices. The Veteran was most recently afforded a VA examination in August 2019. The Veteran reported experiencing flare-ups described as lumbar pain with lifting. The examiner initially recorded flexion to 50 degrees. There was no loss of function or range of motion after repetitive use testing. The examiner observed pain on examination without additional functional loss, but did not observe pain with weight-bearing, passive range of motion, or non-weight bearing. The Veteran was noted to have muscle spasm not resulting in abnormal gait or spinal contour, and normal muscle strength. The examiner found no evidence of ankylosis and no use of assistive devices. The examiner estimated that the Veteran experienced flare-ups once a month, which resulted in a 10 percent loss in range of motion. The examiner noted that the Veteran's functional ability was not significantly limited with flare-ups. Treatment records show back pain and similar levels of impairment, with consistent reports of low back pain. An October 2017 VA treatment note indicates that the Veteran was under the care of a spine specialist and was receiving chiropractic care. The Board acknowledges and has considered the Veteran's reports of symptoms, including recurring pain in the lower back; inability to walk correctly when experiencing pain, loss of power in the legs; painful gait and inability to walk upright. See May 2016 VA Form 9. However, prior to April 26, 2016, the record shows no complaints of flare-ups, and flexion to 90 degrees with pain only at the endpoint. From April 26, 2016, the record shows flexion beyond 30 degrees despite the increased pain during flare-ups and after repetitive use, and there is no evidence demonstrating favorable ankylosis of the entire thoracolumbar spine. While the examiner did not provide the degree at which pain was demonstrated on VA examination in 2019, as flare-ups represent the disability at its worst, and disability ratings are based on actual functional loss not just mere pain (see Mitchell v. Shinseki, 25 Vet. App. 32 (2011)), the Board finds the examiner's estimate of functional loss during a flare-up represents the degree of any functional impairment associated with the Veteran's disability. While the Veteran reported flare-ups at the 2016 VA examination and the examiner did not estimate additional loss of range of motion during such flare-ups, it is not the Veteran's contention that his back disability improved since the 2016 VA examination. Indeed, an increase in loss of range of motion was demonstrated on VA examination in 2019. Thus, the Board finds that the findings noted in 2019, including the examiner's estimation of loss of range of motion during flare-ups, adequately contemplate the degree of any functional impairment demonstrated in 2016. Also, while the Veteran complained of an inability to walk upright during episodes of pain, the objective findings clearly demonstrate he does not have impairment akin to unfavorable ankylosis which is described as the entire thoracolumbar spine or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. He also does not have favorable ankylosis which is described as the spinal segment in neutral position (zero degrees) or the functional equivalent. The Board is not persuaded that the Veteran's temporary occasional episodes of pain that causes him to not straighten his back is of a degree of impairment on par with an individual whose back is permanently fixed. As such, a higher rating is not appropriate for the back disability. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his back disability. Specifically, the 2016 and 2019 VA examiners found no evidence of radiculopathy. The Veteran had full muscle strength, normal reflexes, normal sensation, and a negative straight leg raising test in his lower extremities. The examiners also found no evidence of other neurologic abnormalities. The Board notes a November 2016 VA treatment record documenting the Veteran's complaint of low back pain extending into his hips. Pain is the only symptom the Veteran has endorsed from his back to his lower extremities. The Board is persuaded by the examiner's finding of no radiculopathy, which is based on testing and a comprehensive examination. Moreover, the General Rating Formula contemplates disability of the low back, to include pain, "whether or not it radiates." Also, the Veteran is already service-connected and compensated for disabilities in his hips, including pain. Assigning a separate rating for hip pain under the Diagnostic Code for the spine would constitute impermissible pyramiding. See 38 C.F.R. § 4.14. The Board notes that the Veteran is competent to report on symptoms and sincere in his belief that he is entitled to a higher rating. The Veteran's lay evidence, however, is outweighed by the competent and credible medical evidence that evaluates the true extent of the impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the medical examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints, and to provide the requisite information for an evaluation of the disability under the rating schedule. For these reasons, greater evidentiary weight is placed on the medical findings in regard to the type and degree of the Veteran's impairment. 2. Entitlement to an initial compensable rating prior to April 26, 2016, and in excess of 10 percent thereafter for osteopenia of the left hip 3. Entitlement to an initial compensable rating prior to April 26, 2016, and in excess of 10 percent thereafter for osteopenia of the right hip The Veteran's service-connected osteopenia of the right hip and left hip are each currently rated as noncompensable prior to April 26, 2016 and as 10 percent disabling thereafter under DC 5253. With respect to disabilities of the hip, 38 C.F.R. § 4.71a, Diagnostic Codes 5250 through 5253 set forth relevant provisions. Separate evaluations may be assigned under Diagnostic Codes 5251 (extension), 5252 (flexion), and 5253 (abduction, adduction, or rotation) for disability of the same joint. DC 5250 evaluates ankylosis of the hip. A 60 percent evaluation may be assigned for favorable ankylosis of the hip in flexion at an angle between 20 and 40 degrees and slight adduction or abduction. A higher 70 percent rating is warranted for intermediate ankylosis of the hip, while a maximum 90 percent rating is assigned for unfavorable or extremely unfavorable ankylosis (the foot not reaching the ground, necessitating crutches). The applicable diagnostic codes for limitation of motion of the hip are Diagnostic Codes 5251, 5252 and 5253. Normal ranges of motion of the hip include hip flexion from 0 degrees to 125 degrees, and hip abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.7, Plate II. A 10 percent disability rating is warranted where extension of the thigh is limited to 5 degrees (DC 5251); or where flexion is limited to 45 degrees (DC 5252). A 20 percent disability rating is assigned where flexion is limited to 30 degrees; a 30 percent disability rating is assigned where flexion is limited to 20 degrees; and a 40 percent disability rating is assigned where flexion is limited to 10 degrees. 38 C.F.R. § 4.71a, DC 5252. A 10 percent disability rating is also warranted for limitation of rotation of the thigh if the affected leg cannot toe-out more than 15 degrees; a 10 percent rating is warranted where adduction is limited such that legs cannot be crossed; and a 20 percent rating is assigned for limitation of abduction of the thigh with motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, DC 5253. Notably, there was a regulation change to musculoskeletal ratings effective February 7, 2021. However, the regulations that pertain to the hips have, as is relevant here, not changed. A January 2011 examination of the Veteran's hips revealed in both hips, flexion to 125 degrees, extension greater than 5 degrees, and abduction and adduction not lost beyond 10 degrees. Adduction was not limited such that the Veteran could not cross his legs. Rotation was not limited such that the Veteran could not toe-out more than 15 degrees. No pain was noted in any plane on range of motion testing. During an April 2016 VA examination, testing revealed right hip flexion to 100 degrees, extension greater than 5 degrees, and abduction and adduction not lost beyond 10 degrees. Adduction was not limited such that the Veteran could not cross his legs. Rotation was not limited such that the Veteran could not toe-out more than 15 degrees. Pain on flexion was noted which did not cause functional loss. The Veteran was most recently afforded a VA examination in August 2019. The Veteran reported flare-ups described as bilateral pain with stairs. Physical examination revealed in both hips, flexion to 90 degrees, extension greater than 5 degrees, and abduction and adduction not lost beyond 10 degrees. Adduction was not limited such that the Veteran could not cross his legs. Rotation was not limited such that the Veteran could not toe-out more than 15 degrees. There was no pain on weight bearing, non-weight bearing, or with passive range of motion. There was no pain or tenderness to palpation. There was no crepitus. The Veteran was unable to perform repetitive use testing. The examiner estimated that the Veteran's flare-ups, averaging once per month, resulted in a 10 percent loss of range of motion in each plane. At no point during the relevant appeal period did the Veteran's right or left hip strain merit a compensable rating under the criteria of DC 5250, DC 5251, or DC 5252. Prior to April 26, 2016, there was no evidence of ankylosis, extension was not limited to 5 degrees, flexion was not limited to 45 degrees, and limitation of rotation did not result in an inability to toe-out more than 15 degrees. The Veteran, however, did complain of episodes of pain when he walked. Resolving reasonable doubt in favor of the Veteran, the Board finds that he is entitled to a 10 percent rating but no higher for both hips. From April 26, 2016, even considering range of motion lost during flare-ups, there is no evidence that flexion was limited 30 degrees or that with abduction motion was lost beyond 10 degrees, warranting an evaluation in excess of 10 percent evaluation. The currently assigned ratings are appropriate given the range of motion throughout the appeal period. While the examiner did not provide the degree at which pain was demonstrated on VA examination in 2016, as flare-ups represent the disability at its worst, and disability ratings are based on actual functional loss not just mere pain (see Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Board finds the 2019 examiner's estimate of functional loss during a flare-up represents the degree of any functional impairment associated with the Veteran's disability. In regard to the Veteran's reported flare-ups, it is not the Veteran's contention that his hip disability improved over the course of this appeal. Thus, the Board finds that the findings noted in 2019, including the examiner's estimation of loss of range of motion during flare-ups, adequately contemplate the degree of any functional impairment demonstrated on past examinations. The Board notes that the Veteran is competent to report on symptoms and sincere in his belief that he is entitled to a higher rating. The Veteran's lay evidence, however, is outweighed by the competent and credible medical evidence that evaluates the true extent of the impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the medical examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints, and to provide the requisite information for an evaluation of the disability under the rating schedule. For these reasons, greater evidentiary weight is placed on the medical findings in regard to the type and degree of the Veteran's impairment. 4. Entitlement to a total disability rating based on individual unemployability (TDIU), prior to October 22, 2015 As noted, the RO granted entitlement to a TDIU, effective October 22, 2015. However, a TDIU prior to October 22, 2015 must be considered. A total disability rating may be assigned where the schedular rating is less than total when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16 (a). Nevertheless, even when a Veteran does not meet the percentage standards for schedular TDIU, he may be considered for TDIU on an extraschedular basis pursuant to 38 C.F.R. § 4.16 (b). However, the Board does not have the authority to assign extraschedular TDIU in the first instance. See 38 C.F.R. § 4.16 (b). During the relevant period prior to October 22, 2015, the Veteran is service connected for: chronic dermatitis, rated as 30 percent disabling effective November 2008; hepatocellular carcinoma due to chronic hepatitis with cirrhosis, rated as 30 percent disabling, effective October 2009; osteopenia of lumbar spine associated with hepatocellular carcinoma due to chronic hepatitis with cirrhosis, rated as 10 percent disabling, effective October 2010 and 20 percent disabling effective April 2016; osteopenia, right hip associated with hepatocellular carcinoma due to chronic hepatitis with cirrhosis, will be rated 10 percent effective October 2010 (as the result of this decision) and 10 percent disabling effective April 2016; and osteopenia, left hip associated with hepatocellular carcinoma due to chronic hepatitis with cirrhosis, will be rated as 10 percent effective October 2010 (as the result of this decision) and 10 percent disabling effective April 2016. The Veteran's hepatocellular carcinoma due to chronic hepatitis, and hips and back disabilities result from a common etiology and combine for 51 and when combined with the skin disability, the Veteran has a combined rating of 70 percent. 38 C.F.R. § 4.25. Thus, the Veteran meets the schedular criteria. In Ray v. Wilkie, the Court held that the phrase "unable to secure and follow a substantially gainful occupation" in section 4.16(b) has two components: one economic and one noneconomic. Id. at 73. The economic component "simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person." 31 Vet. App. 58, 72-73 (2019). As for the "noneconomic component," the Court held that this refers to the individual claimant's "ability to secure or follow" an occupation earning more than marginal income. Id. (emphasis in original). In determining whether a Veteran can secure and follow a substantially gainful occupation, the Court stated that attention must be given to several relevant factors: (1) the Veteran's occupational history, education, skill, and training; (2) whether the Veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g. sedentary, light, medium, heavy, or very heavy) required by the occupation at issue; and (3) whether the Veteran has the mental ability to perform the activities required by the occupation at issue. Id. The Court noted that these potentially relevant factors were not a "checklist that must be completely run through in every case," and that any factor need only be discussed if the evidence raises it as an issue. Id. Regarding the physical limitations factor, the Court stated that relevant considerations include, but are not limited to, the Veteran's limitations with respect to lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations. Id. Regarding the mental ability factor, the Court stated that relevant considerations include, but are not limited to, the Veteran's limitations with respect to memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Id. The Board first considers the economic component. The Veteran states that he worked from 1984 to June 2004 as a postal clerk, earning approximately $43,000 a year in 2000. The Veteran states that he stopped working due to complications from a liver transplant. The Veteran contends that the pain in his back and hips prevent him from working. He indicated he completed three years of college education. As such, the Board finds the evidence indicates the Veteran was unemployed from June 2004. Of note, during a September 2008 VA examination to assess the severity of the Veteran's hepatocellular carcinoma, the examiner noted that the Veteran underwent a liver transplant and subsequent surgeries due to complications of the transplant. The examiner noted current symptoms of abdominal epigastric cramping that occurred in response to prolonged sitting, which subside with movement and relaxation. The examiner stated that the Veteran was otherwise asymptomatic in regard to his liver transplant. Regarding the Veteran's chronic dermatitis, a May 2009 VA examiner found no functional impairment. Regarding the Veteran's lumbar spine and bilateral hip disabilities, a January 2011 VA examiner noted that the Veteran's primary symptoms are pain and fatigue, but found no painful movement of the hips and pain at the endpoint of flexion of the lumbar spine. The Board finds that the Veteran's disabilities significantly impacted his ability to sit and walk. Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran's service-connected disabilities rendered him unemployable prior to October 22, 2015. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Bynum, 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.