Citation Nr: 21041399 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 13-24 123 DATE: July 9, 2021 ORDER Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial compensable rating for hemorrhoids is denied. Entitlement to service connection for a cyst on the head is denied. REMANDED Entitlement to an initial rating in excess of 10 percent for right index finger gout, to include arthritis and other associated right hand/finger disabilities, is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for upper and lower back pain is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's PTSD has been productive of occupational and social impairment due to mild or transient symptoms; more severe impairment has not been shown. 2. The Veteran's hemorrhoids have been no more than moderate in degree and have not been productive of large or thrombotic hemorrhoids that are irreducible and have excessive redundant tissue, evidencing frequent occurrences; persistent bleeding with secondary anemia or with fissures has also not been demonstrated. 3. The Veteran reported that symptoms related to a cyst on the head had resolved. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. 2. The criteria for entitlement to an initial compensable rating for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.114, DC 7336. 3. The criteria for entitlement to service connection for a cyst on the head have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active and Reserve duty from November to December 1989, March 1990 to September 1992, January to July 2001, August 2001 to June 2002, January 2005 to January 2006, March to July 2006, September 2006 to July 2007, and May 2009 to January 2009 and active duty training from June to August 1988 and June to September 1989. These matters arose to the Board of Veterans' Appeals (Board) from a January 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes the Veteran requested Board hearings regarding this appeal in the past, most recently on a May 2019 VA Form 9. In that correspondence, he stated he was living overseas but would be able to attend a videoconference hearing if given 30-60 days of notice. Thereafter, the RO scheduled a videoconference in late August 2019, and the Veteran was notified of this in June 2019, more than 60 days prior to the scheduled hearing. He did not appear for the hearing, did not offer good cause for his failure to appear, and has not thereafter requested a hearing be rescheduled. The issue was not raised in the Veteran's representative's May 20201 Informal Hearing Presentation (IHP). The Board deems the hearing request withdrawn. The Board previously remanded these issues for further evidentiary development in November 2020. Following the Board's remands, the RO granted the Veteran's claims for entitlement to service connection for a right shoulder disability, stomach disability, and skin disability, to include dermatitis, in a February 2021 rating decision. Those issues are no longer on appeal. In that same February 2021 rating decision, a higher initial rating of 30 percent was granted for PTSD. In a March 2021 rating decision, a higher initial rating of 10 percent was granted for right index finger gout. Because higher ratings are available for PTSD and disabilities of the hand, the Veteran is presumed to seek the maximum available benefit, the claim for a higher initial rating for PTSD remains on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); AB v. Brown, 6 Vet. App. 35 (1993). Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.159 (2020). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. No substantive argument was raised in the May 2021 IHP. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Rating Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 1. Entitlement to an initial rating in excess of 30 percent for PTSD The Veteran contends he is entitled to an initial rating in excess of 30 percent for his PTSD. For the following reasons, the Board finds the claim must be denied. The Veteran's PTSD symptoms are rated under 38 C.F.R. § 4.130, DC 9411. All psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). Id. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. Finally, a total schedular rating of 100 percent is warranted when the disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, all ratings in the general rating formula are associated with objectively observable symptomatology, and in Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." The Federal Circuit further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. Thus, "[a]lthough the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas.'" Id. at 118. As such, the Board will consider both the Veteran's specific symptomatology as well as the occupational and social impairment associated with the DC to determine whether an increased evaluation is warranted. As with all claims for VA disability compensation, the Board must assess the credibility and weigh all the evidence, including lay and medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert denied, 523 U.S. 1046 (1998). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126; see Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. Id. The "such symptoms as" language means "for example," and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 11617 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought, or other symptoms of similar severity, frequency, and duration. Id. at 117. VA must engage in a holistic analysis that assesses the severity, frequency, and duration of the signs and symptoms of the psychiatric disability; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The Board notes that the Diagnostic and Statistical Manual, Fourth Edition, allowed for the assignment of Global Assessment of Functioning (GAF) scores, which are a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. However, VA regulations were amended to adopt the Diagnostic and Statistical Manual, Fifth Edition (DSM-5), which eliminated the use of GAF scores for evaluating mental illness. 80 Fed. Reg. 14,308 (Mar. 19, 2015). As GAF scores are no longer held to be an effective method of evaluating the severity of psychiatric disabilities, the Board will not rely on any GAF scores in adjudicating the present claim. Golden v. Shulkin, 29 Vet. App. 221, 22426 (2018). This appeal stems from the Veteran's November 2010 claim. In October 2011, the Veteran received a VA Compensation and Pension (C&P) examination in which the examiner determined the Veteran was suffering from a mental disability, but his symptoms were not severe enough to interfere with occupational and social functioning or to require continuous medication. Socially, the Veteran indicated he saw his one daughter as frequently as possible. The Veteran was employed full-time and after his work in an office as a security advisor for a major oil company, he studied at home for his master's degree. For hobbies, the Veteran traveled. When at work, if the Veteran felt he was backed into a corner by his co-workers, he could become unreasonable but not violent. Mentally, the Veteran had normal cognitive functioning, appeared his stated age, was casually dressed and neatly groomed. His affect was normal; his speech was with a normal rate, tone, and pressure. His eye contact was good, and his thought process was linear and goal directed. His sleep was, however, poor, and he had difficulty falling asleep and woke easily. He stated he was always thinking of the places he was in, and dreams disrupted his sleep approximately two to three times a week. He ate a healthy diet but was unable to exercise due to pain issues. The Veteran's activity level was average, as were his cognitive abilities. There was no indication of psychosis with no reported auditory or visual hallucinations, and he was not experiencing suicidal or homicidal thoughts. The Veteran reported difficulty with insomnia and feelings of fear and helplessness. The Veteran was no longer able to be in crowds or in big spaces, such as malls. He stated he profiled people who looks Middle Eastern and noted high levels of hyperstartle response, hypervigilance, dissociated behavior, emotional numbing and anger and irritability; he had difficulty talking about his experience while he was in the service. He stated that since service he had become more withdrawn and does not trust people. He was never able to let down his guard or trust people. The examiner determined the Veteran was fully employed and fully employable without any significant difficulties at work. Symptomatically, the examiner noted the Veteran experienced depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. In his August 2013 VA Form 9, the Veteran stated he took medication for his PTSD and had missed work and had difficulty adjusting and forming permanent relationships as a result of his psychiatric symptoms. In a May 2019 VA Form 9, filed in response to an SSOC, the Veteran reported suffering night terrors, sleeplessness, and anxiety due to PTSD and said he had to miss work due to his symptoms. In December 2020, the Veteran received an additional C&P examination in which the examiner determined the Veteran suffered from occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Veteran informed the examiner that he had difficulty with insomnia and symptoms of PTSD. He said he can no longer be in crowds or in big spaces. He had difficulty going to malls because he felt uncomfortable with many people in wide open spaces. He had high levels of hypervigilance, dissociative behavior, emotional numbing, and anger and irritability, and had difficulty talking about his experience while he was in the service. He did not trust people and was not currently participating in formal treatment. The Veteran reported he maintained contact with his older sister and had been married to his current wife for five years, with whom he has two children. Occupationally, the Veteran had recently earned his masters degree in human security and peace building and worked as a security advisor for a major oil company. However, he informed the examiner he was recently terminated from his job due to a poor performance evaluation due to his PTSD symptoms. Symptomatically, the Veteran experienced depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, and an inability to establish and maintain effective relationships. The examiner observed that the Veteran was casually dressed and neatly groomed. His affect was normal, and his speech was within a normal rate, tone, and pressure. His eye contact was good, and his thought process with linear and goal directed. His sleep was poor, as he noted that he had difficulty falling asleep and waked easily. His cognitive ability appeared to be average, and there was no indication of psychosis with no reported auditory or visual hallucinations. He was not experiencing suicidal or homicidal thoughts at the time of the examination. The Veteran was able to maintain activities of daily living, including his personal hygiene. He had not experienced significant trauma over the last year, and his symptoms were continuous. He did not have problems with drug and alcohol abuse, and there was no sign of inappropriate behavior. His thought processes and communication were not impaired. His social functioning was somewhat impaired as the examiner noted the Veteran could tend to isolate and had difficulty being out in public. After a thorough review of the evidence, the Board finds that the Veteran's PTSD symptoms do not warrant an increased initial rating. In the aggregate, and particularly in consideration of the reports from the Veteran's C&P examinations and his lay statements and testimony regarding his symptoms, the Board finds the evidence demonstrates that the Veteran suffers from occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). In short, the record fairly shows that the Veteran's PTSD has caused, among other symptoms, depressed mood, anxiety, suspiciousness, and chronic sleep impairment. He has also reported feeling uncomfortable in crowds and confined spaces, as well as interpersonal difficulties. Such symptoms are consistent with the current 30 percent rating. The Board finds, however, that the Veteran's disability pictures does not more nearly approximate occupational and social impairment with reduced reliability and productivity. The record contains no evidence of memory impairment or angry outbursts that may reasonably reflect impaired impulse control and possibly impaired judgment and abstract thinking. During the period on appeal, the Veteran married, had another child, completed his master's degree, and until recently had maintained fulltime employment (the issue of entitlement to a TDIU is discussed in the Remand section below). The Board has also considered various other symptoms reported by the Veteran, such as social anxiety and depressed moodnone of these symptoms are of similar severity, duration, or frequency as to warrant a 50 percent rating under the relevant criteria. The Board notes that the Veteran struggles with his ability to establish and maintain effective work and social relationships, but his impairment in this regard does not rise to the level of a 50 percent rating. The Board further is aware of the C&P findings noting inability to establish and maintain effective relationships. While the Board acknowledges the examiner's expertise and understands this is one of the symptoms listed in the 70 percent rating criteria, the Board does not believe the Veteran's overall impairment rises to a level justifying a higher rating. As to his relationships, the Board reiterates that the Veteran is married with children, has completed a graduate degree, and overall has not reported an "inability" to have relationships. To the extent the record shows disturbances of motivation and mood (a symptoms listed in the 50 percent criteria), the Board likewise finds the Veteran's overall impairment does not rise to the level necessary for a 50 percent rating, i.e., reduced reliability and productivity. The Veteran's PTSD has not been shown to result in total occupational and social impairment, as the Veteran has been able to maintain close relationships (i.e., his marriage, children, school, and employment). He therefore cannot be considered "totally" impaired socially or occupationally. (Having difficulties at work due to mental health or PTSD symptoms, as the Veteran has indicated, is not the same as being totally unable to function in a work environment.) Furthermore, the C&P examinations did not demonstrate that the Veteran suffered from gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, or a persistent danger of hurting self or others. He has also not been shown to have intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. No other symptoms of similar severity, frequency, and duration to those listed under the 100 percent criteria have been demonstrated. In sum, since the Veteran's claim for service connection was granted, the evidence of record demonstrates the overall impairment caused by his PTSD more nearly approximates occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. More severe occupational and social impairment has not been established. Thus, an increased initial rating is not warranted. 2. Entitlement to an initial compensable rating for hemorrhoids The Veteran contends he is entitled to an initial compensable rating for hemorrhoids. The Veteran's symptoms are rated under DC 7336. 38 C.F.R. § 4.114. Under that DC, a noncompensable rating is warranted for hemorrhoids that are mild or moderate; a 10 percent rating is warranted where there is evidence of large or thrombotic hemorrhoids, which are irreducible, with excessive redundant tissue, evidencing frequent recurrences; a maximum schedular rating of 20 percent is warranted where hemorrhoids are present, with persistent bleeding and secondary anemia, or with fissures. Id. On review, the Board finds that the criteria for a compensable rating have not been met at any time during the appeal period. At the Veteran's only C&P examination, in December 2020, the examiner determined the Veteran suffered from mild or moderate internal or external hemorrhoids. The Veteran's condition began in 1991 with such symptoms as constipation and rectal bleeding. In 2015, the condition was treated with a colonoscopy, fiber supplements, and medication. Currently, the Veteran suffered from symptoms such as constipation, rectal bleeding, and pain; he stated his hemorrhoids would bulge and bleed one to three times per month. For treatment, the Veteran utilized medication. The examiner determined the Veteran's hemorrhoids were not large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. Furthermore, they did not cause persistent bleeding, leading into secondary anemia, or contain fissures. In essence, the examiner determined the Veteran suffered from small or moderate external hemorrhoids without any other pertinent physical findings, complications, conditions, signs or symptoms. In addition to the VA examination reports discussed above, the Board has reviewed the Veteran's private medical records. These records provide no indication the Veteran's hemorrhoids have ever been large or thrombotic, irreducible, manifested by excessive redundant tissue, persistent bleeding, or prone to frequent recurrence. There is likewise no evidence that the Veteran has ever been treated for anemia or anal fissures. The Board acknowledges the Veteran's general lay reports of hemorrhoid-related symptomatology, including pain and bleeding. Notwithstanding, he has never specifically asserted that his hemorrhoids have been large or thrombotic, irreducible, manifested by excessive redundant tissue, or prone to frequent recurrence. Rather, his lay statements are consistent with mild or moderate hemorrhoids, and thus align with his current noncompensable evaluation. In light of the lay and medical evidence discussed above, the Board finds that the most probative evidence of record demonstrates that the criteria for a compensable rating have not been met. Accordingly, the claim for an increased rating must be denied. Service Connection 3. Entitlement to service connection for a cyst on the head The Veteran contends he is entitled to service connection for a cyst on the head. For the following reasons, the Board finds service connection not warranted. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). A review of the record shows the Veteran was seen in March 2002 for a painful cyst on his head. In an August 2013 VA Form 9, the Veteran noted a cyst had appeared on his head in boot camp and had never disappeared. In December 2020, the Veteran received a C&P examination to, under the Board's instructions, determine whether he had a cyst on his head. The examiner noted prior evidence of a cyst in the service treatment records and post-service records. However, the Veteran informed the examiner his symptoms involved mainly skin problems which began in 2005 as a rash following exposure to burn pits overseas. He reported being treated by four different doctors via ointments and lotions, and stated his current symptoms were redness, itchiness, and a burning sensation. A diagnosis of eczema was noted. The Veteran informed the examiner his cyst on his head had resolved and, following a complete examination, the examiner was unable to find evidence of any cyst on the Veteran's head. Following the December 2020 examination, the RO awarded the Veteran service connection for eczema of the scalp. The Board notes that Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). In this case, the Board finds the opinion of an expert VA clinician in conjunction with the Veteran's own statements that the Veteran does not have a cyst, and the Veteran's comment to the examiner that the cyst had resolved, to be probative evidence indicating a lack of a current disability. There is no evidence of treatment or complaints of a cyst (as opposed to skin-related symptoms that have subsequently been service-connected) at any time during the appeal period. The Board is not free to reject medical evidence on the basis of its own unsubstantiated medical conclusions. Flash v. Brown, 8 Vet. App. 332 (1995).) In sum, in light of the absence of any probative evidence of a diagnosis of a cyst at any point during the pendency of the Veteran's appeal, the claim must be denied. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is inapplicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 4. Entitlement to an initial rating in excess of 10 percent for a right index finger disability is remanded. The Veteran has been assigned an initial 10 percent rating for his right index finger disability, characterized as gout. The Board is aware that DC 5229, the RD under which this disability is rated, provides a maximum 10 percent rating for limited motion of that finger. 38 C.F.R. § 4.71A, DC 5229. On review, however, the Board finds there is evidence the relevant disability might involve the Veteran's entire hand. Historically, the Veteran injured his right hand in service from an explosion. He initially failed to report for an examination was service-connected for gout in his right index finger; the RO claimed this was the only disability that could be identified in his service treatment records. The Veteran has raised the possibility that this was an incomplete diagnosis and indeed according to his most recent C&P examination he denied having gout but instead reported arthritis. His VA medical records show he has this diagnosis; a September 2008 treatment note indicates he complained of right hand pain with possible arthritis. In addition, the C&P report reflects the Veteran complained of whole-hand pain, swelling, and limited mobility. Higher ratings are potentially available for disability involving multiple fingers of the hand. The Board finds another examination is necessary to determine whether the Veteran's service-connected disability involves multiple fingers, and if so, the extent of such disability, so that VA can properly rate the Veteran's symptoms. 5. Entitlement to service connection for a left shoulder disability is remanded. The Veteran contends he is entitled to service connection for a left shoulder disability. At a December 2020 C&P examination, the examiner determined there were "no signs of aggravation of the preexisting left shoulder condition/surgery." The examiner gave no explanation for this conclusion, nor did he discuss the Veteran's lay statements, in which he complained of worsening symptoms since his time in service. Accordingly, prior to adjudication, an additional examination is necessary. 6. Entitlement to service connection for upper and lower back pain is remanded. The Veteran contends he is entitled to service connection for upper and lower back pain. At a December 2020 C&P examination, the examiner repeated, word for word, the Board's instructions to discuss the Veteran's lay statements that he had to wear over 100 pounds of gear in service but did not actually discuss those statements and then found no nexus by stating merely: "there is no record of treatment or complaints found during periods of service for any back spine conditions." In stating this, the examiner neglected to address the Board's remand instructions to discuss the Veteran's lay statements, and failed to address the Veteran's service treatment records discussing back pain in July 2007 and December 2008. The Board cannot rely upon such a conclusion, which relies so heavily upon the absence of service treatment records. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). An updated examination and opinion is needed. 7. Entitlement to service connection for a right ankle disability is remanded. The Veteran contends he is entitled to service connection for a right ankle disability. At a December 2020 C&P examination, the examiner determined the Veteran's right ankle disability was not related to service. Again, in coming to this conclusion, he failed to discuss the Veteran's reports of pain since service, as directed in the Board's remand instructions, and relied only on a lack of injury in the Veteran's service treatment records. Lay evidence concerning the onset of symptoms, if credible, is competent, regardless of the lack of contemporaneous medical evidence. Id. 8. Entitlement to service connection for a left ankle disability is remanded. The Veteran contends he is entitled to service connection for a left ankle disability. At a December 2020 C&P examination, he reported symptoms of pain and functional loss of ability in his left ankle. The examiner, however, determined the Veteran suffered from no disability and therefore proffered no nexus opinion. Given that pain is considered an impairment of earning capacity, an additional examination and opinion is in order. See Saunders v. Wilkie, 886 F.3d 1356, 1364-68 (Fed. Cir. 2018) (holding that where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability for VA purposes). 9. Entitlement to a TDIU is remanded. At the Veteran's most recent PTSD C&P examination, the report reflects that he stated he was recently fired from work due to his PTSD symptoms. This raises the issue of entitlement to a TDIU, which is part and parcel of the increased ratings claims on appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has not yet received appropriate notice regarding entitlement to a TDIU, however. This should be done on remand. Moreover, the TDIU claim is intertwined with the claims discussed above. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the nature and severity of his right index finger disability, to include associated arthritis or other disability of fingers on the right hand. The examiner is asked to review the claims file and provide the following information: (a) Identify and describe all symptoms and manifestations attributable to the service-connected disability. All necessary diagnostic testing and evaluation should be performed, including range of motion testing for flexion and extension, in both passive and weight-bearing situations. (b) Clarify the appropriate diagnosis for the Veteran's right finger disabilities. (c) The examiner should opine as to whether there are any disabilities of the non-index fingers on the right hand, and whether such are related to the Veteran's in-service injury that led to the grant of service connection for her right index finger. (d) Determine whether the index finger or other associated finger disabilities exhibit pain or painful motion, weakened movement, premature or excess fatigability, or incoordination; and, if feasible, these determinations should be expressed in terms of the degree of additional functional loss, including in terms of what effect, if any, this has on the range of motion, including during times when these symptoms are most problematic ("flare ups") or during prolonged, repetitive, use of the knees. (e) Inquire whether there are periods of flare-ups and, if the answer is yes, to state their "severity, frequency, and duration; name the precipitating and alleviating factors; and estimate, 'per [the] veteran,' to what extent, if any, they affect functional impairment. 2. Schedule the Veteran for a VA examination by an examiner to determine the nature and etiology of the Veteran's left shoulder disability. The examiner is asked to review the claims file and provide the following information: (a) State whether the criteria for a diagnosis are met. (b) Opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's disability was incurred in or otherwise related to the Veteran's service. (c) If it is determined that there is another likely etiology for the Veteran's disability, that should be stated. (d) The examiner should specifically discuss the Veteran's lay assertions of in-service incurrence and continuous symptoms of pain since service. The examiner should set forth all examination findings, with a clear rationale for the conclusions reached. 3. Schedule the Veteran for a VA examination by an examiner to determine the nature and etiology of the Veteran's upper and lower back disability. The examiner is asked to review the claims file and provide the following information: (a) State whether the criteria for a diagnosis are met. (b) Opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's disability was incurred in or otherwise related to the Veteran's service. (c) If it is determined that there is another likely etiology for the Veteran's disability, that should be stated. (d) The examiner is specifically asked to comment on the Veteran's reports of in-service incurrence, to include in-service instances of pain in July 2007 and December 2008, as well as his reports of continuous symptoms of pain since service. The examiner should set forth all examination findings, with a clear rationale for the conclusions reached. 4. Schedule the Veteran for a VA examination by an examiner to determine the nature and etiology of the Veteran's bilateral ankle disabilities. The examiner is asked to review the claims file and provide the following information: (a) State whether the criteria for a diagnosis are met. In this, the examiner is reminded that pain, especially when resulting in functional loss, is considered a disability for VA purposes. (b) Opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's disabilities were incurred in or otherwise related to the Veteran's service. (c) If it is determined that there is another likely etiology for the Veteran's disabilities, that should be stated. (d) The examiner should specifically discuss the Veteran's lay assertions of in-service incurrence and continuous symptoms of pain since service. (Continued on the next page) The examiner should set forth all examination findings, with a clear rationale for the conclusions reached. 5. Mail the Veteran notice and any appropriate paperwork regarding the issue of entitlement to a TDIU. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ryan, 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.