Citation Nr: 21040938 Decision Date: 07/07/21 Archive Date: 07/07/21 DOCKET NO. 05-03 779 DATE: July 7, 2021 ORDER Entitlement to service connection for a bilateral ankle disability is denied. Entitlement to service connection for a lumbar spine disability is denied. Entitlement to service connection for a skin disorder is denied. Entitlement to service connection for tuberculosis (TB) is denied. An initial rating of 30 percent, but no higher, for peripheral neuropathy of the right upper extremity (PN RUE) is granted. An initial rating of 20 percent, but no higher, for peripheral neuropathy of the left upper extremity (PN LUE) is granted. An initial rating of 20 percent, but no higher, for peripheral neuropathy of the bilateral lower extremities (PN BLE) is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The Veteran's bilateral ankle disability was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 2. The Veteran's lumbar spine disability was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that the Veteran's skin disorder began during active service or is otherwise related to an in-service injury or disease. 4. The Veteran's TB was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 5. Resolving reasonable doubt in the Veteran's favor, his peripheral neuropathy of the bilateral upper extremities (PN BUE) manifested with moderate incomplete paralysis of the median nerve. 6. Resolving reasonable doubt in the Veteran's favor, his peripheral neuropathy of the bilateral upper extremities (PN BLE) manifested with moderate incomplete paralysis of the sciatic nerve. 7. The Veteran's service-connected disabilities did not preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral ankle disability are not met. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 2. The criteria for service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 3. The criteria for service connection for a skin disorder are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 4. The criteria for service connection for tuberculosis (TB) have not been met. 38 U.S.C. §§ 1110, 1112, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 5. The criteria for an initial rating of 30 percent, but no higher, for PN RUE have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8515 (2019). 6. The criteria for an initial rating of 20 percent, but no higher, for PN LUE have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8515 (2019). 7. The criteria for an initial rating of 20 percent, but no higher, for PN BLE have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8520 (2019). 8. The criteria for a total disability rating based on individual unemployability (TDIU) have not been met. 38 U.S.C. §§ 1155, 5107, 7104 (2012); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.10, 4.15, 4.16 (a) (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the U.S. Army from August 1969 to August 1971, including service in the Republic of Vietnam from January 1971 to August 1971. Sadly, the Veteran died in May 2019. His surviving spouse has been substituted as the appellant. This case comes before the Board on appeal of rating decisions in July 2004, March 2009, April 2010, and March 2012. This case was previously before the Board in February 2021, where the issues on appeal were remanded for further evidentiary development. The Board notes that the Veteran's service connection claim for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) with depressive disorder and adjustment disorder was granted in an April 2021 rating decision. Therefore, as the service connection claim has been granted, it is resolved and no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement (NOD) thereafter must be timely filed to initiate appellate review of the claim concerning "downstream" issues such as the compensation level assigned for the disability and effective date). Service Connection Generally, to establish service connection a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may also be granted through the application of statutory presumptions for chronic conditions, which includes hypertension, sensorineural hearing loss and tinnitus. See 38 C.F.R. §§ 3.303 (b), 3.309 (a) (2019); see also 38 U.S.C. §§ 1112, 1137 (2012). First, a claimant may benefit from a presumption of service connection where a chronic disease has been shown during service. 38 C.F.R. § 3.303 (b). In the alternative, if a chronic disease was not shown in service, but manifested to a degree of 10 percent or more within some specified time after separation from active service, such disease shall be presumed to have been incurred or aggravated in service, even if there is no evidence of such disease during service. 38 U.S.C. §§ 1112, 1137 (2012); 38 C.F.R. § 3.307 (a)(3) (2019). The application of these presumptions operates to satisfy the "in-service incurrence or aggravation" element and establish a nexus between service and a present disability, which must be found before entitlement to service connection can be granted. Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303 (b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303 (b). For a chronic disease to be considered to have been "shown in service," there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in-service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. Additionally, service connection may be granted on a secondary basis. Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310 (2019). To prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board notes that the Veteran's service in the Republic of Vietnam would entitle him to certain presumptions; however, none of service connection claims relate to one of the enumerated disabilities under 3.309 (e). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Likewise, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be more persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b) (2012). 1. Entitlement to service connection for a bilateral ankle disability Here, the appellant contends that the Veteran's bilateral ankle disability was caused or incurred during active duty service. Based on the evidence, the Board disagrees. At the outset, the Veteran was diagnosed with left ankle tendonitis and degenerative changes. Likewise, VA treatment records indicated bilateral osteoarthritis of the ankles. Thus, the first element of service connection is met. Additionally, the second element is met for the left ankle. Specifically, the Veteran's service treatment records (STRs) contain evidence of two left ankle sprains in April and July 1971 while playing basketball. The Board notes however, that the Veteran contended that his left ankle was injured in June 1971 during a Jeep accident that resulted in him being medevacked for treatment. However, the evidence of record fails to support the Veteran's recollection of his left ankle injury. Regarding the left ankle disability, to warrant service connection the third element requires a nexus, or link between the in-service injury and the Veteran's diagnosed left ankle condition. In that regard, in the April 2021 VA medical opinion, the examiner, J.W., opined that the Veteran's left ankle condition was not caused or related to active duty service. The examiner reasoned that although the Veteran did experience a left ankle injury twice during service, both injuries were clearly stated to have resulted from playing basketball and were diagnosed and treated with conservative measures as acute ankle sprains. There was no mention of any other left ankle injuries and/or of any Jeep accident or helicopter evacuation. The examiner added that there was also no mention of any disability at the time of the Veteran's discharge later that year in August 1971. The records did not document nor even suggest/refer to the incidents that the Veteran described as related to his left ankle. Moreover, the examiner explained that the Veteran was diagnosed with bilateral ankle sprain in the May 2005 VA examination. The May 2005 examiner indicated that the Veteran's ankles were new conditions relative to his military service of 34 years prior. Examiner J.W. stated that the Veteran was subsequently diagnosed with minimal osteoarthritis of the left ankle in September 2005 and inflammatory changes of the tibialis anterior of the left ankle in March 2006. The examiner continued that bilateral ankle MRIs performed in 2015 (44 years post discharge from service) found tendinosis and chronic disruption of several ligaments in the Veteran's left ankle, and tenosynovitis along with complete disruption of the anterior talofibular ligament in the right ankle. J.W. explained that the diagnosis of "sprain" suggests an acute, transitory condition (usually arising from a specific injury/incident) which is self-limiting (resolves with time and/or appropriate treatment) and occurs in the general active population. J.W. added that the Veteran's STRs do not show any evidence that his two episodes of acute left ankle sprains did not resolve with treatment as would be expected. She continued that the although the Veteran had been diagnosed with a bilateral ankle "sprain" at the time of the 2005 VA examination (decades after the Veteran's in-service left ankle sprains), there was no objective clinical evidence that those disabilities were related to his active military service (to include the remote left ankle sprains) and/or that the diagnosed right ankle sprain was related to/caused by left ankle condition. Furthermore, J.W. explained that in regard to the Veteran's mild degenerative joint disease (DJD/osteoarthritis) of the left ankle (noted on x-ray of September 2005, when the Veteran was 55-years-old), most commonly results from chronic "wear and tear" which occurs overtime as a result of normal physical activities. She added that according to "UpToDate," these radiographic changes are frequently found in adults over the age of 30. In fact, advanced age is one of the strongest risk factors associated with DJD/OA, with studies consistently finding the prevalence of this disease to be less than 0.1 percent in those aged 25 to 34 years old versus a rate of over 80 percent in people over age 55. J.M explained that the condition (which involves bony structures) would be unrelated to a remote ligament sprain. Lastly, J.W. stated that the Veteran's left and right ankle tendinosis and ligament disruptions (which were diagnosed almost 45 years post service) cannot be objectively felt to be causally related to the acute left ankle sprains that the Veteran experienced in 1971. In addition to being diagnosed after many decades of normal aging and "wear/tear," the Veteran also had a work history which was repeatedly documented to involve physical activity and walking, along with weight gain of 51 lbs. (from 160 lbs. at discharge to 211 lbs. in 2015). She concluded that all of these factors were most likely involved as etiology of the bilateral ankle ligament and tendon conditions found in 2015. The Board finds the examiner's opinion to be competent, credible, and highly probative. The examiner reviewed the pertinent evidence, accounted for the Veteran's lay assertions, and provided an opinion based on the evidence and medical principles. The Board acknowledges the statements made by the Veteran and furthered by the appellant, but neither has the specialized training or education to determine the etiology of the Veteran's left ankle condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, the Board has also carefully considered the articles submitted by the Veteran regarding chronic ankle pain and the healing of soft tissues. The Court (CAVC) has indicated that treatise evidence may suffice to establish nexus in instances where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Sacks v. West, 11 Vet. App. 314, 317 (1998). Significantly however, the Court has also held that treatise materials generally are not specific enough to show nexus, id. at 317, and that medical opinions directed at specific patients generally are more probative than medical treatises. Herlehy v. Brown, 4 Vet. App. 122, 123 (1993). In this instance, the medical articles submitted do not pertain to the Veteran per se, rather it's a general discussion on chronic ankle pain and soft tissue injuries, which is not as probative as the medical opinion concerning the Veteran's condition. Moreover, the more probative evidence is against finding that the Veteran's left ankle condition was caused or incurred in service or manifested to a compensable degree within a year of discharge. Furthermore, as it regards his right ankle disability, the Veteran's STRs are silent any complaints, treatment, or diagnosis of a right ankle disability. In fact, the Veteran argued that his right ankle disability was caused by his left ankle disability because he favored his right side. However, service connection on a secondary basis for the right ankle is not warranted as service connection for the left ankle has not been granted. Accordingly, as the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application and the claims must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 2. Entitlement to service connection for a lumbar spine disability Here, the appellant contends that the Veteran's lumbar spine disability was caused or incurred during active duty service or secondary to his left ankle disability. Based on the evidence, the Board disagrees. At the outset, the Veteran was diagnosed with degenerative changes of the lumbar spine in the May 2012 VA examination. Likewise, in VA treatment records, it was shown that the Veteran had degenerative disc disease (DDD) of the lumbar spine complicated by L5/S1 annular tear and facet degenerative joint disease (DJD). Thus, the first element of service connection is met. Additionally, the second element is met. Specifically, the Veteran's STRs showed that in November 1969, the Veteran complained of and was treated for back pain. Likewise, in July 1970, the Veteran complained of pain in the lumbar area of the spine. The Board notes that on separation there was no mention of back pain, but the in-service incurrences of back pain satisfy the second element. Therefore, to warrant service connection there must be a nexus, or link between the Veteran's in-service complaints and the diagnosed DDD of the lumbar spine, which is generally proven by medical evidence. In that regard, in the September 2020 VA medical opinion, the physician, Dr. L.Z., opined that the Veteran's lumbar spine disability was less likely than not incurred in or caused by the in-service injury. Dr. L.Z. explained that the Veteran was diagnosed with lumbar degeneration in a VA evaluation in 2012. His review of the STRs revealed complaints of back pain in November 1969 and July 1970. Dr. L.Z. stated that the hand-written records were scratchy but indicated that the Veteran had to get a urine test. However, the rest of the STRs were silent for any back complaint. Dr. L.Z. explained that the STRs suggested that the Veteran could have had a mechanical lumbar spine injury, namely a lumbar strain. Dr. L.Z. explained that muscle strains and ligament sprains are two of the most common diagnoses made for lower back pain. Sprains and strains of the lumbar spine could result from heavy lifting, excessive exercise, or unusual movement during a fall or a motor vehicle accident. He continued that with proper care and treatment, the pain of less severe lumbar sprains and strain typically lasts about 5 to 10 days. Most lumbosacral injuries resolve within 6 weeks regardless of type of treatment. He added that if proper rehabilitation is provided, sprain and stain should heal without any residual change in function. Dr. L.Z. stated that review of the STRS did not demonstrate evidence of recurrent or chronic lower back condition. Dr. L.Z. explained that the cause of current diagnosis of DDD/DJD is unknown. It has been thought to be multifactorial. Aging is a risk factor for lumbar disc degeneration. In individuals of all ages undergoing MRI, 30 percent of those without symptoms showed disc degeneration. Among individuals 60 years or age and older, 57 percent had abnormalities. The tendency to develop lumbar disc degeneration appears to be genetic in some cases. The Board finds the physician's opinion to be competent, credible, and highly probative. Dr. L.Z. reviewed the pertinent evidence, accounted for the lay statements, and provided an opinion consistent with the evidence and medical principles. The Board notes that the Veteran contended that his back disability was secondary to his left ankle due to compensating for his left ankle. See March 2004 Statement in support. Although the Board acknowledges this contention, as decided herein, the Veteran's left ankle disability is not service-connected. Therefore, service connection for the lumbar spine disability as secondary to the left ankle is not warranted. Moreover, there is no evidence that the Veteran's lumbar spine condition manifested to a compensable degree within a year of discharge. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 3. Entitlement to service connection for a skin disorder Here, the appellant contends that the Veteran had a skin disorder that was caused or incurred during active duty. Based on a preponderance of the evidence, the Board disagrees. At the outset, the Veteran was diagnosed with tinea pedis in a March 2017 VA examination. At that time, the Veteran reported having intermittent itchy bumps to the hands for the past 40+ years. Likewise, during the December 2008 VA examination, the Veteran reported that since 1970 he has had itching in his hands and legs, arms and back, with periodic tiny white bumps that showed up. Thus, the first element of service connection is met. Additionally, the second element is met. Specifically, the Veteran's STRs showed that in April 1970, the Veteran suffered from contact dermatitis of both hands due to an allergy to soap powder. Likewise, in June 1970, the Veteran was treated for contact dermatitis of both hands. Therefore, to warrant service connection there must be a nexus, or link between the Veteran's contact dermatitis during service and the diagnosed tinea pedis, which is generally proven by medical evidence. In that regard, in the April 2021 medical opinion the examiner, J.W. opined that the Veteran's skin disorder was less likely than not caused by or incurred in service. The examiner explained that the Veteran was seen and given a profile in 1970 for contact dermatitis of both hands (felt related to detergent). She continued that there were no other medical visits during service for any skin complaints and there was no mention of any chronic skin disorder/condition at the time of the Veteran's separation examination in 1971. She added that the Veteran's post discharge medical records were silent for any mention of skin symptoms or complaints until 2004 (many decades post discharge) when the Veteran reported a new issue with toenail fungus and was diagnosed with onychomycosis of the left big toenail. She continued that in 2007, the Veteran reported a recurrent rash on his feet, which was diagnosed as tinea pedis and in November 2008, he was seen for diffuse rash over many areas of his body (and given a steroid) without a clear diagnosis listed. There were no further mentions of any skin conditions found in subsequent records. J.W. continued that no skin lesions or rash was noted during the November 2008 VA examination, and during the March 2017 VA examination, diagnoses of "contact dermatitis in 1970" and tinea pedis (from 2008) were listed but physical examination found only "minimal scaling to soles of feet" and no rash/lesions on the Veteran's hands were present at that time. J.W. added that there was no clinical evidence that the Veteran's onychomycosis/tinea unguium (fungal infection of toenail) which were initially diagnosed in 2004 and 2008, respectively, are causally related to his military service of decade prior to their appearance and diagnosis. J.W. explained that these were very common skin disorders present in the general population (per UpToDate, "dermatophyte infections are common worldwide") with increasing prevalence and increased risk for the condition with advancing age. In addition, tinea pedis "may accompany onychomycosis," and as they are caused by fungal organisms, have no causal relationship with "contact dermatitis" and/or eczema. J.W. explained that in contrast to skin infections associated with a fungus, irritant contact dermatitis (ICD) "is a localized inflammatory skin response to a wide range of chemical or physical agents" resulting from "direct cytotoxic effect of irritants and, unlike allergic contact dermatitis, is not immune mediated" (again as per UpToDate). The most common clinical expression of allergic contact dermatitis (ACD) is "an eczematous dermatitis that can be mild to severe, acute and short lived, or chronic." J.W. added that the literature indicated that the most common contact allergens are plants, nickel, and cosmetics and personal care products (such as hair dyes, sunscreen, glue, etc.). She continued that the Veteran's skin condition in 1970 was clearly felt secondary due to his exposure to some type of detergent, but one clinic note stated, "allergy to soap." She advised that there was no indication that the medical providers undertook any specific evaluation/testing in regard to this diagnosis, instead appearing to have rendered a diagnosis based on some criteria not readily apparent in their notes. J.W. concluded that the Veteran may have had an episode of either contact dermatitis or allergic dermatitis specific to a specific substance in 1970; however, his medical records do not document any chronic, ongoing skin complaints associated with a contact type dermatitis. It was many decades after discharge (2007) when the Veteran was diagnosed with some type of eczematous dermatitis and there was just no objective clinical evidence that this disorder was causally related to (or the same as) the one isolated, remote episode of contact dermatitis the Veteran experienced in 1970. The Board finds J.W.'s opinion to be competent, credible, and highly probative. J.W. reviewed the entire record, accounted for the lay assertions, and provided an opinion based on the evidence and medical principles. The Board acknowledges the appellant's contentions but neither her nor the Veteran have the specialized training or education to render an etiology opinion regarding his skin condition. As such, the more probative evidence is against finding that the Veteran's skin condition was caused or incurred in service. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). 4. Entitlement to service connection for tuberculosis (TB) Here, the appellant contends that the Veteran had tuberculosis that was caused or incurred during service. Based on a preponderance of evidence, the Board disagrees. At the outset, the Veteran had a diagnosis of tuberculosis as documented in a May 2005 VA treatment record. Thus, the first element of service connection is met. However, the second element is not met. The Veteran's STRs are silent for any complaints, treatment, or a diagnosis of tuberculosis or symptoms associated with tuberculosis. Conversely, on several occasions the Veteran reported that he was diagnosed with TB during service. Specifically, in the March 1974 VA benefits application, the Veteran indicated treatment for tuberculosis in 1969 at Fort Polk, Louisiana. Then, in a September 2003 correspondence, the Veteran indicated that he tested positive for TB in December 1969, and again reiterated that in an April 2005 DRO hearing. However, contrary to the Veteran's assertions, he tested negative for TB in December 1969, and again tested negative in November 1970. See STRs. Furthermore, in the April 2021 medical opinion, J.W. opined that the Veteran's TB was less likely than not incurred in or caused by his active service. J.W. explained that after careful review of the STRs she did not find any mention of exposure to and/or diagnosis of tuberculosis during the Veteran's active service. She added that while the Veteran made a claim for TB in 1974, indicating TB in 1969, the statements could not be objectively verified. J.W. explained that the STRS indicated that the Veteran tested negative for TB (via skin testing) twice during service (in 1969 and 1970), and also had no evidence of disease on the routine chest x-ray performed in conjunction with his separation examination in August 1971. J.W. continued that while it is possible that the Veteran's skin/PPD test in 1969 was not performed routinely but as a result of some exposure (as the Veteran indicated in 2005), the fact that the Veteran received a number of vaccinations at the same time would argue against this, and the test was clearly recorded as negative (as was one the following year). Additionally, the Veteran reported having been treated with medication for TB at the Dallas VAMC in 1971 to 1974, also receiving medication treatment at a clinic in 1996, but was informed that he "couldn't take it anymore because it would mess up my kidneys and my liver." Again, J.W. was unable to find any documentation to support the Veteran's assertions. J.W. stated that records did show that in February 1994 (greater than 20 years post discharge), the Veteran had a positive PPD (the first documented indication of or reference to TB), and subsequent medical records show numerous chest imaging studies performed from 1994 through 2016 (done in regard to the positive PPD or for other complaints/issues/disorders) which failed to find any evidence of active (or past infection with) tuberculosis. J.W. explained that review of the medical literature (see UpToDate) in regard to "latent tuberculosis infection" (as opposed to active TB infection) finds that LTBI is a clinical diagnosis that is established by demonstrating prior TB infection as a per a positive tuberculin/PPD skin test (TST) and excluding active TB disease (via clinical history, physical examination, chest x-ray, and respiratory samples if indicated). J.W. added that guidelines for treatment of TB did not correlate to the treatment and regiment described by the Veteran. Specifically, treatment for active pulmonary TB generally involves two phases combining for a total treatment time of six to nine months, as opposed to ongoing treatment for years, as indicated by the Veteran. J.W. concluded that there is evidence of two negative skin tests in service, no documentation of TB in the STRs and routine chest x-ray at discharge which was negative for the disease. The Board finds the medical opinion to be competent, credible, and highly probative. J.W. reviewed the record, accounted for the Veteran's assertions, and provided an opinion based on the evidence and medical principles. Based on the foregoing, the Board finds that the preponderance of the evidence is against finding that the Veteran's TB was caused or incurred in service. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2019). Increased Rating Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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. To evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Additionally, separate ratings for distinct periods of time, based on the facts may be for consideration. Fenderson v. West, 12 Vet. App. 119 (1999). The Board has reviewed all the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as deemed appropriate and the analysis will focus on what the evidence shows, or fails to show, as to the claims. 5. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the bilateral upper extremities (PN BUE) 6. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the bilateral lower extremities (PN BLE) Here, the appellant contends that the Veteran's PN BUE/BLE warranted a rating in excess of 10 percent disabling. Resolving reasonable doubt in the Veteran's favor, the Board agrees. At the outset, the Veteran's PN BUE are rated under DC 8515 for the median nerve. The evidence reflects that the Veteran was right-handed; accordingly, his right upper extremity is his major (dominant) extremity and his left upper extremity is his minor (non-dominant) extremity. For the major (dominant) extremity: a 10 percent disability rating is warranted for mild incomplete paralysis; a 30 percent disability rating is warranted for moderate incomplete paralysis; and a 50 percent disability rating is warranted for severe incomplete paralysis. A 70 percent disability rating is warranted for complete paralysis of the median nerve, with the following: the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. For the minor (non-dominant) extremity: a 10 percent disability rating is warranted for mild incomplete paralysis; a 20 percent disability rating is warranted for moderate incomplete paralysis; a 40 percent disability rating is warranted for severe incomplete paralysis; and an 60 percent disability rating is warranted for complete paralysis, as described above. 38 C.F.R. § 4.124a, DC 8515. The peripheral neuropathy of the left lower extremity and right lower extremity are currently rated under DC 8520, which provides ratings for paralysis of the sciatic nerve. DC 8520 indicates that mild incomplete paralysis is rated 10 percent disabling; moderate incomplete paralysis is rated 20 percent disabling; moderately severe incomplete paralysis is rated 40 percent disabling; and severe incomplete paralysis with marked muscular atrophy is rated 60 percent disabling. Complete paralysis of the sciatic nerve, that is, where the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost, is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. These descriptive words "mild," "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. Resolving reasonable doubt in the Veteran's favor, the Veteran's PN BUE/BLE manifested with moderate incomplete paralysis. In a July 2006 treatment record, the Veteran reported decreased sensation to the lateral aspect of his left. He also reported a burning and tingling sensation that occurred with walking that radiated up his leg to his lumbar spine. Testing revealed decreased sensation throughout left toes/foot/leg and decreased to lateral aspect of right thigh. Vibration was mildly decreased in toes bilaterally symmetrically. Yet, the physician concluded that there was no evidence of peripheral neuropathy. In the November 2008 VA examination, the Veteran presented with numbness in his right thigh and transient numbness in the hands and feet, but nothing persistent. He had no difficulty using the hands. There were no distal symptoms of any persistent or frequent nature. However, sensory examination impacted sensation to light touch and vibration in the fingers and toes of all extremities. In the January 2011 VA examination, the Veteran presented with loss of sensation as a peripheral neuropathic symptoms. The Veteran had numbness from his right thigh down to his ankle and pain in his right great toe. On examination, vibration testing was absent on the LLE. He had decreased sensation to pinprick testing on his foot. His RLE yielded absent vibration testing and decreased pinprick sensation throughout the foot. The Veteran had at least active movement against some resistance for all extremities bilaterally. Likewise, there was no evidence of muscle atrophy. In an addendum, the examiner indicated that the Veteran had numbness, pain, and loss of sensation in both feet. In a July 2011 VA examination, the Veteran had decreased vibratory sensation, pinprick sensation and monofilament testing in the upper and lower extremities. He had absent deep tendon reflexes of both ankles, decreased deep tendon reflexes for the upper extremities. There was no evidence of muscle spasms. However, there was atrophy of both upper and lower extremities. Lastly, in the March 2017 VA examination, the Veteran reported having burning to the bottoms of his feet which started years prior. On examination, the Veteran had decreased deep tendon reflexes in his BLE. Additionally, he had decreased sensation to light touch. However, there was no evidence of muscle atrophy. The Board notes that VA treatment records showed that the Veteran complained of burning sensation in his forearms, decreased sensation to light touch and vibrations in his extremities. There were also records that showed the Veteran had sensation intact bilaterally. Based on the foregoing, and resolving reasonable doubt in the Veteran's favor, his peripheral neuropathy manifested with moderate incomplete paralysis of the median and sciatic nerves. The frequency, severity, and duration of the Veteran's PN most closely approximates a moderate level of severity. However, the evidence does not show that the Veteran's condition was moderately severe or severe. Accordingly, an assignment of 30 percent disabling, but no higher, for PN RUE, 20 percent, but no higher for PN LUE under DC 8515 is warranted. Likewise, an assignment of 20 percent, but no higher for PN BLE under DC 8520, is warranted. 7. Entitlement to a total disability rating due to individual unemployability (TDIU) A TDIU rating may be granted upon a showing that the Veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. See 38 C.F.R. § 4.16 (a) (2019). There are minimum disability rating percentages that must be shown for the service-connected disabilities, alone or in combination, to even qualify for consideration for a TDIU award under § 4.16(a). Indeed, if there is only one such disability, it must be rated at 60 percent or more; if instead there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. Id. The United States Court of Appeals for Veterans Claims (CAVC) has indicated that the unemployability question, or the veteran's ability or inability to engage in substantial gainful activity, must be looked at in a practical manner and that the crux of the matter rests upon whether a particular job is realistically within the capabilities, both physical and mental, of the appellant. See Moore v. Derwinski, 1 Vet. App. 356 (1991). 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). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19 (2019); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). "Substantially gainful" employment is employment that is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides. See Moore v. Derwinski, 1 Vet. App. 356, 358 (1991) (adding that the definition of substantially gainful employment suggests a living wage). Marginal employment is not considered substantially gainful employment. See 38 C.F.R. § 4.16 (a); see also Moore, 1 Vet. App. at 358 ("The ability to work only a few hours a day or only sporadically is not the ability to engage in substantially gainful employment."). In reaching a decision, it is necessary that the record reflect some factor, which takes the case outside the norm with respect to a similar level of disability under the rating schedule. 38 C.F.R. §§ 4.1, 4.15 (2019); Van Hoose, 4 Vet. App. 361. The fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether the Veteran is capable of the physical and mental acts required by employment, not whether he can find employment. See Beaty v. Brown, 6 Vet. App. 532, 538 (1994). The fact that a veteran is unemployed or has difficulty finding employment does not alone warrant assignment of a TDIU, as a high rating itself establishes that his or her disability makes it difficult for her to obtain and maintain employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Rather, the evidence must show that he is incapable "of performing the physical and mental acts required" to be employed. Id. at 363; 38 C.F.R. § 4.16 (a). Thus, the central question is whether a veteran's service-connected disabilities alone are of sufficient severity to produce unemployability, and not whether a veteran could find employment. Id. Consideration may be given to a veteran's education, training, and special work experience, but not to his or her age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Here, the appellant contends that the Veteran was entitled to TDIU due to his service-connected disabilities. Based on the evidence, the Board disagrees. At the outset, the Veteran met the schedular criteria for TDIU. He was service-connected for PTSD at 30 percent disabling; diabetes at 20 percent disabling; and as decided herein, PN RUE at 30 percent disabling; PN LUE at 20 percent disabling; PN LLE at 20 percent disabling; PN RLE at 20 percent disabling. For a combined rating of 80 percent disabling. Therefore, the Board must determine whether the Veteran's service-connected disabilities precluded him from obtaining and maintaining substantially gainful employment. In this instance, in the November 2008 VA examination, the Veteran's medical history showed that he was a 58-year-old former route salesman for cakes and snack who was on Social Security Disability because of low back pain. In his VA 21-8940, the Veteran reported that his back, ankles, vision and diabetes precluded him from obtaining or maintaining substantially gainful employment. The Veteran was a self-employed route salesman that finished high school and two years of college. He then specified that his ankle, back and diabetes precluded employment. Then, in a statement in support, the Veteran explained that he became permanently disabled in 2005, from injuries he had in the military to his left ankle and back. The Veteran added that the medications for his PTSD caused him to be immobile. However, in his mental status evaluation, it was shown that prior to his retirement in 2006, he worked for the last 21 years in sales selling snack food to grocery stores. He reported that during the 21 years that he was in sales he worked for three different companies. He denied that he was ever fired or disciplined for any actions during his time with those companies and stated that he moved on to difference companies in order to gain more money. He denied any history of significant occupational impairment. Moreover, in April 2007 VA examination, the examiner stated that the Veteran was placed on disability and could no longer work primarily due to his left ankle condition. The examiner added that the Veteran had chronic low back pain and could not stand or walk for long periods because of chronic low back pain. Furthermore, in the March 2017 VA examination, the examiner indicated that the Veteran's diabetes did not impact his ability to work. The Board finds that the Veteran's service-connected disabilities did not preclude him from obtaining or maintaining substantially gainful employment. The Veteran retired in 2006 and was placed on disability due to his back and left ankle disability, which are not service-connected. Based on the evidence, the Veteran's psychiatric condition and diabetes did not impact his employability. Although the Veteran expressed that his diabetes and PTSD caused him issues, the preponderance of the evidence shows that his chronic back and left ankle pain limited his mobility to the point of requiring him to retire. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2019). KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. Umo, 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.