Citation Nr: 21041529 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 16-39 433 DATE: July 9, 2021 ORDER Entitlement to service connection for a left knee disorder, to include as secondary to the service connected residuals of a right knee disorder is denied. Entitlement to a compensable evaluation for post-traumatic headaches is denied. Entitlement to a total disability rating based on individual unemployability is denied. FINDINGS OF FACT 1. The evidence does not support a finding that the Veteran's left knee disorder is proximately related to his service connected right knee disorder or is otherwise related to or aggravated by an in-service injury or disease. Arthritis did not manifest to a compensable degree within one year of separation from service. 2. The evidence supports a finding that the severity, frequency, and duration of the Veteran's post-traumatic headaches is not manifested by characteristic prostrating attacks averaging one in two months over the last several months 3. The Board finds that the pertinent and more probative evidence of the record does not demonstrate that the Veteran's service connected disabilities alone were of sufficient severity to render him unable to secure and maintain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disorder, to include as secondary to the service-connected residuals of a right knee disorder are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.303, 3.3 3.309, 3.310. 2. The criteria for a compensable evaluation for post-traumatic headaches are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 8100, 8045. 3. The criteria for a total disability rating based on individual unemployability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341(a), 4.1, 4.16, 4.19, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from June 1973 to October 1974. This matter was most recently remanded by the Board in November 2018. Development has been accomplished and the above issues are now before the Board. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, 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" the so-called "nexus requirement." Holton v. Shinseki 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, a preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). For Veterans with 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including arthritis, may be presumed to have been incurred in service if they manifest to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). Increased Ratings 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 the 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. While it is necessary to consider the complete medical history of the Veteran's condition in order to evaluate the level of disability and any changes in condition, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); Francisco v. Brown, 7 Vet. App. 55 (1994). In deciding the Veteran's increased evaluation claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. Headaches As of October 23, 2008, Diagnostic Code 8045 provides for the evaluation of TBI, under which there are three main areas of dysfunction listed that may result from TBI and have profound effects on functioning: Cognitive (which is common in varying degrees after TBI), emotional/behavioral and physical. Each of these areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a. Records reveal that when service connection was granted for the residuals of a TBI, and post-traumatic headaches, a 10 percent rating was assigned under Code 8045 primarily for findings of headaches. As the originating agency has noted, there is some question whether a separate headache rating was for assignment, but it was nevertheless established. The initial rating under Code 8045 noted minimal symptoms under the new code and continued the 10 percent rating. The issue of an increased rating for the residuals of a TBI is not at issue herein, other than as it impacts headaches. The Veteran's post-traumatic headaches are currently evaluated under Diagnostic Code 8100 which provides for migraine headaches. Under Diagnostic Code 8100, headaches, with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability are rated as 50 percent disabling; With characteristic prostrating attacks occurring on an average once a month over last several months are rated as 30 percent disabling; With characteristic prostrating attacks averaging one in 2 months over last several months are rated as 10 percent disabling; and with less frequent attacks are rated as noncompensable. Diagnostic Code 8100. TDIU The Board notes that, generally, total disability will be considered to exist when there is present any impairment of mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings are authorized for any disability or combination of disabilities for which the Schedule for Rating Disabilities prescribes a 100 percent disability evaluation, or, with less disability, if certain criteria are met. Id. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned 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 ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where a Veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16 (b). This cannot be awarded by the Board in the first instance, but only considered after a preliminary referral to the Director of the Compensation service. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may not be given to the impairment caused by nonservice connected disabilities. See 38 C.F.R. §§ 3.34, 4.16, 4.19. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Substantially gainful employment is defined as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a Veteran actually works and without regard to a Veteran's earned annual income. See Faust v. West, 13 Vet. App. 342 (2000). The determination as to whether TDIU is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-32 (1991). 1. Entitlement to service connection for a left knee disorder, to include as secondary to the service-connected residuals of a right knee disorder The Veteran contends that his left knee disorder is proximately related to his service connected right knee disorder, or in the alternative was incurred in service. Service treatment records (STRs) do not reveal any complaints, diagnosis, or treatments for a left knee disorder. At an examination before discharge, the Veteran did not report, nor did the examiner diagnose any left knee disorder. The Veteran did sustain a right knee disorder while playing football on one occasion. This resulted in some period of casting and limited profile. Service connection for a right knee disorder has been granted and a 10 percent rating assigned. In a September 2008 VA joints examination, the examiner did not diagnose the Veteran with any left knee disorders, nor did the Veteran report any left knee pain. In a March 2010 VA joints examination, the examiner diagnosed the Veteran with left knee chondromalacia. The examiner opined that it is less likely than not that the Veteran's left knee pain is a continuation of reported left knee pain in-service. The examiner explained that there is no documentation in the Veteran's STRs of complaints or treatment for left knee pain. VA outpatient treatment records reveal that the Veteran regularly underwent treatment for his left knee pain after 2010. Specifically, June 2012 VA orthopedic x-ray findings reveal degenerative joint disease of the left knee. In a March 2013 VA orthopedic note, the Veteran reported left knee pain with a five year history. In a June 2013 VA General examination, the examiner diagnosed the Veteran with degenerative joint disease of the left knee. The examiner opined that the Veteran's left knee disorder is less likely than not proximately due to the result of the Veteran's service connected right knee disorder. The examiner noted that the Veteran's problems in one knee would not cause problems in his opposite knee. The examiner explained that since a person is bi-pedal (uses both legs to walk), when he is having problems in one knee, he is off both knees more. SSA records do not reveal that the Veteran is receiving disability benefits for his left knee disorder. In a February 2019 VA knee examination, the examiner diagnosed the Veteran with a left knee meniscal tear and left knee osteoarthritis with an onset of 2008. Regarding functional and occupational limitations, the examiner noted that the Veteran's left knee disorder limits his ability to participate in physical employment that requires weight-bearing, standing, or walking. In a February 2019 VA knee examination, the examiner diagnosed the Veteran with a left knee meniscal tear and left knee osteoarthritis. In a January 2020 VA knee examination, the examiner diagnosed the Veteran with degenerative arthritis of the left knee. The examiner opined that the Veteran's left knee disorder is less likely than not proximately due to or the result of the Veteran's service connected disorders. The examiner explained that the Veteran's STRs do not show any evidence of treatment for a left knee disorder in-service. The examiner also noted that there is no evidence of a left knee disorder being due to a right knee disorder during service. Thus, a nexus has not been established. Regarding functional and occupational limitations, the Veteran reported having lost two to four weeks of work due to his left knee pain. The examiner also noted that the Veteran's bilateral degenerative arthritis of the left knee makes it difficult to walk or stand for long periods. The Board also reviewed the Veteran's lay statements asserting that the onset of his left knee disorder is related to his service connected right knee disorder. Lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses. However, the Board must emphasize that the Veteran is not competent to interpret accurately clinical findings pertaining to a left knee disorder as this requires highly specialized knowledge and training. 38 C.F.R. § 3.159 (a)(1) (2018). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). To summarize, the Veteran's STRs reveal no complaints, diagnosis, or treatments for any left knee disorders related to his service or his service-connected right knee disorder. Furthermore, there is no indication of any complaints or treatments for any left knee disorder related to service for many years post-service. See Mason v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is evidence against a claim of service connection). This premise is further evidenced by the fact that the Veteran did not file a compensation claim for his service-related left knee disorder until many years after discharge. Moreover, it is not shown that the right knee disorder was so severe as to alter the Veteran's gait or otherwise create excessive stress on the left knee. As such, the foregoing summary of the treatment record reveals no possibility for service connection for a left knee disorder on a secondary basis. Although the Veteran contends that the onset of his left knee disorder is related to his service connected right knee disorder, there is no in-service treatment for left knee problems, or for many years after discharge. Moreover, the Veteran was not diagnosed, nor did he report any left knee problems at various VA outpatient examinations post-service. In-fact, in a March 2013 VA orthopedic note, the Veteran reported left knee pain with a five year history. Furthermore, the Board acknowledges the January 2020 VA addendum opinion, the examiner opined that the Veteran's left knee disorder is less likely than not proximately due to or the result of the Veteran's service connected disorders. Thus, a nexus has not been established. There is no persuasive clinical opinion to the contrary. As the claims file lacks evidence of a left knee disorder secondary to the Veteran's service connected right knee disorder, the Board finds that the evidence of the record indicates that the onset of the Veteran's left knee disorder is less likely than not related his service connected right knee disorder. As a pathology for a left knee disorder has not been shown to be related to the Veteran's service connected right knee disorder, the Board finds that the clinical evidence does not support the Veteran's contentions. Based on this evidence, the Board finds service connection is not warranted. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claim, the doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 3.102. 2. Entitlement to a compensable evaluation for post-traumatic headaches The Veteran contends that he is entitled to a compensable evaluation for his post-traumatic headaches. In an April 2010 rating decision, the Veteran was originally granted service connection for the residuals of a traumatic brain injury (TBI) and assigned a 10 percent evaluation effective April 25, 2008 under Diagnostic Code 8045. The regional office (RO) evaluation was assigned based on the Veteran's history and testimony reporting that he injured his head twice in-service. One injury occurred in October/ November 1973 during airborne jump school training. The Veteran's other head injury occurred during a motorcycle accident in November 1973. Lastly the Veteran reported an additional post-service head injury December 2009. The RO assignment of the rating was also based on the Veteran's VA examination which diagnosed a mild TBI with post-traumatic headaches. The Veteran also reported symptoms of headaches, dizziness, insomnia, with no reporting of dementia. In the same April 2010 rating decision, the Veteran was assigned a separate noncompensable evaluation for post-traumatic headaches effective October 23, 2008 under Diagnostic Code 8100. The RO assigned the evaluation based on the Veteran's reporting in a 2010 VA examination of non-prostrating headaches two to three times a week which last thirty minutes to an hour. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a 10 percent disability rating. The Veteran's symptoms more closely approximated the symptoms associated with a noncompensable rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a noncompensable rating. January 2009 VA outpatient treatment records reveal that the Veteran presented with complaints of headaches. The Veteran reported headaches with vision impairment triggered by bright lighting. The Veteran also reported that his headaches can linger for several hours. In a March 2010 VA TBI examination, the examiner diagnosed the Veteran with post-traumatic headaches. The Veteran reported non-prostrating headaches that occur two to three times a week lasting approximately thirty minutes. The Veteran denied nausea and vomiting but did report symptoms of dizziness and visual impairment. The Veteran reported that his post-traumatic headaches caused occasional interference with his workplace and social interaction. This appears to be essentially compensated by the rating assigned under Code 8045. June 2012 VA CT head scan findings reveal a diagnosis of sinus disease. In a January 2013 VA outpatient neurology consultation, the Veteran reported headaches with nausea and throbbing pain as a result of a 1973 motorcycle accident. The Veteran was prescribed oxygen therapy for his residual headaches. In a June 2013 VA General examination, the examiner diagnosed the Veteran with migraines with nausea and light sensitivity, but no evidence of prostrating attacks or syncope episodes. The Veteran reported that his headaches improved due to oxygen therapy treatment. Regarding functional and occupational impairment, the Veteran reported that he was employed at a glass company as a machinist from 1999 to 2008. The Veteran reported that his headaches are the largest contributor to his inability to work. January 2014, May 2014, and June 2014 VA neurology consultations reveal that the Veteran underwent oxygen therapy treatment for his headaches. SSA records do not reveal that the Veteran is receiving disability benefits for his post-traumatic headaches. Headaches were not figured in the disability determination made. VA outpatient treatment records reveal that the Veteran regularly underwent treatment for his post-traumatic headaches during the period on appeal. In a February 2019 VA headaches examination, the examiner diagnosed the Veteran with migraines. During the examination the Veteran reported headaches two to three times a week lasting no more than a day. The Veteran also reported the use of over the counter medication to treat his headaches. The Veteran also reported prostrating attacks once a month. Regarding functional and occupational impairment, the examiner noted that the Veteran's reported history of syncope episodes impacts his ability to work. The examiner noted that the Veteran should avoid driving, operating machinery, standing in water, swimming, taking baths, or climbing ladders. August 2014 to May 2019 VA outpatient neurology consultations reveal that the Veteran reported improvement with oxygen therapy for his headache disorder. Specifically, in a May 2019 consultation, the Veteran reported symptoms of dizziness and possible fainting during an ongoing headache flare-up. The Veteran also reported that his last episode occurred three weeks prior to the examination. The examiner advised the Veteran to not operate a motor vehicle if he was experiencing syncope episodes. In a January 2020 VA headaches examination, the examiner diagnosed the Veteran with post-traumatic headaches. The examiner noted nausea, sensitivity to light, sensitivity to sound, and changes in vision with a duration of less than a day and no evidence of prostrating attacks. Regarding functional and occupational impairment, the Veteran reported difficulty focusing on task. The Veteran reported two to four weeks of lost work time in the past twelve months. The examiner also reported that the Veteran's posttraumatic headaches makes it difficult to focus on a task The Board also reviewed and carefully considered the Veteran's lay statements asserting that the severity of his service-connected post-traumatic headaches warranted a compensable evaluation. Lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses and there is no reason to doubt his credibility. However, the Board must emphasize that the Veteran is not competent to interpret accurately clinical findings pertaining to the severity of his post-traumatic headaches as this requires highly specialized knowledge and training. 38 C.F.R. § 3.159 (a)(1). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board acknowledges the February 2019 conflicting examiner opinion. The Veteran reported prostrating attacks and a history of syncope episodes which severely impacts his ability to work. Significantly, this does not seem to be confirmed by other evidence on file. When evaluating medical opinions, it is the province of the Board to weigh the evidence and decide where to give credit and where to withhold the same, and in so doing, to also accept certain medical opinions over others. See Evans v. West, 12 Vet. App. 22, 30 (1999). The Board cannot make its own independent medical determinations, and there must be plausible reasons for favoring one opinion over another. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail and whether there was review of the Veteran's claims file. Prejean v. West, 13 Vet. App. 444 (2000). An evaluation of the probative value of a medical opinion or diagnosis is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusions reached. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When confronted with conflicting medical opinions, the Board must weigh each and favor one competent medical expert over another if its statement of reasons and bases is adequate to support that decision. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board must also determine which of the competing medical opinions is more probative of the medical question at issue. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). The Board finds that the basis of the February 2019 examiners opinion focused solely on the Veteran's reported history of syncope and prostrating attacks and not the findings of actual diagnostic testing. Moreover, the examiner did not address the Veteran's employment history post-service for many years which permitted the Veteran to operate heavy machinery despite his reported loss of consciousness episodes. Furthermore, the examiner did not discuss any findings in the record to support the Veteran's reported history of frequent syncope episodes. While the Veteran reports that the severity of his post-traumatic headaches has increased, the competent and more credible evidence of record reveals that the Veteran's post-traumatic headaches are not manifested by prostrating attacks averaging one in two months over the last several months. Furthermore, recent VA examiner findings reveal that the severity, frequency, and duration of the Veteran's posttraumatic headaches had decreased over time with oxygen therapy treatment. Moreover, there was no evidence or reporting by the Veteran that he experienced prostrating attacks. Although the Veteran has reported that the severity of his post-traumatic headaches has resulted in his inability to work, these statements are not supported by the medical evidence in the record. Moreover, as noted above, the Veteran was employed from 1999 to 2008 as a machinist at a glass bottling company where he operated heavy machinery. The Board has determined that it unlikely that the Veteran would have been permitted to operate heavy machinery if he was experiencing syncope episodes due to his post-traumatic headaches. As such, the Board finds the severity, frequency, and duration of the Veteran's symptoms more closely approximates the symptoms contemplated by a noncompensable evaluation, which are less severe, less frequent, and shorter in duration than those contemplated by a 10 percent rating. The Board finds that based on the evidence of the claims file the noncompensable evaluation currently assigned better approximates the trajectory of the Veteran's current post-traumatic headaches symptoms. As the Board reviewed the Veteran's records and determined that they do not support a compensable evaluation for this disorder, the evidence for this period preponderates against an increase so reasonable doubt provisions are inapplicable. 38 C.F.R. § 3.102. 3. Entitlement to a total disability rating based on individual unemployability The Veteran essentially contends that he is entitled to a total disability rating based on individual unemployability. The Veteran submitted a November 2018 compensation claim based on individual unemployability. At the time, the Veteran reported that he was employed at a glass container company as a machinist from 1999 to 2008 with a salary of $4,000 a month. The Veteran also reported that his employment ended when his headaches and right knee symptoms rendered him too disabled to secure and follow substantially gainful employment. There is some evidence of a dispute over workmen's compensation regarding the back and right knee. The Veteran is service connected for the following disorders: residuals of a right knee disorder at 10 percent; traumatic brain injury at 10 percent; and posttraumatic headaches at 0 percent. As the Veteran does not have a single service-connected disability ratable at 60 percent or more, or there are not more than two or more disabilities with one at least ratable at 40 percent or more, and a sufficient additional disability to bring the combined rating to 70 percent or more, the Veteran does not currently meet the schedular requirements for consideration of individual unemployability. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In a September 2008 VA joints examination, the examiner diagnosed the Veteran with osteochondritis of the right knee. Regarding occupational and functional limitations, the examiner noted that the Veteran reported being fired in March 2008 due to a conflict with workers compensation. The Veteran also reported that although his right knee was bothering him at work, he was able to manage. In a March 2010 VA joints examination, the examiner diagnosed the Veteran with swelling and crepitus of the right knee. The Veteran reported injuring his right knee in a post-service 2008 forklift accident. The Veteran reported that after the forklift accident he did not return to work. The Veteran also reported difficulty walking, standing, and lifting. In a March 2010 VA TBI examination, the examiner diagnosed the Veteran with a mild traumatic brain injury and the headaches. The Veteran reported injuring his right knee in a post-service 2008 forklift accident. The Veteran reported that after the forklift accident he did not return to work. The examiner noted that the Veteran has three or more subjective symptoms that mildly interfere with work activities and one or more neurobehavioral effects that occasionally interfere with workplace and social interaction. In a June 2013 VA knee examination, the examiner diagnosed the Veteran with degenerative joint disease of the right knee. Regarding occupational and functional limitations, the examiner noted that the Veteran's right knee disorder prevent him from prolonged lifting, stooping, and using the stairs. The examiner noted that the Veteran was last employed in a manufacturing company making and packing bottles for a beverage company. The examiner determined that it is unlikely that the Veteran would be capable of sustaining this type of employment as a means of support due to his right knee disorder. SSA records do not reveal that the Veteran is receiving disability benefits for any of his service connected disorders. The Veteran receives SSA benefits for his low back pain and obesity. In a February 2019 VA knee examination, the examiner diagnosed the Veteran with a right knee osteoarthritis with an onset of 2008. Regarding functional and occupational limitations, the examiner noted that the Veteran's right knee disorder limits his ability to participate in physical employment that requires weight-bearing, standing, or walking. In a February 2019 VA headaches examination, the examiner diagnosed the Veteran with migraines. During the examination the Veteran reported headaches two to three times a week lasting no more than a day. The Veteran also reported the use of over the counter medication to treat his headaches. The Veteran also reported prostrating headache pain once a month. Regarding functional and occupational impairment, the examiner noted that the Veterans reported history of syncope episodes impacts his ability to work. The examiner noted that the Veteran's headaches with reported syncope cause him to be at risk for injury due to residual syncope. The examiner advised the Veteran not to drive, operate heavy machinery, stand in water, stand in close proximity to open flames, climb ladders, or do anything else that would place him at risk. In a January 2020 VA headaches examination, the examiner diagnosed the Veteran with posttraumatic headaches. The examiner noted nausea, sensitivity to light, sensitivity to sound, and changes in vision with a duration of less than a day and no evidence of prostrating attacks. Regarding functional and occupational impairment, the Veteran reported difficulty focusing on task. The Veteran reported two to four weeks of lost work time in the past twelve months when working, but not currently working. The examiner also reported that the Veteran's headaches make it difficult for him to focus on task. In a January 2020 VA knee examination, the examiner diagnosed the Veteran with degenerative arthritis of the right knee. Regarding functional and occupational limitations, the Veteran reported having lost two to four weeks of work due to his right knee pain, again when last working, but currently unemployed. The examiner also noted that the Veteran's bilateral degenerative arthritis of the knees makes it difficult to walk or stand for long periods. The Board finds that while the Veteran's service connected disabilities render him unable to perform certain types of labor; nonetheless, the evidence of record does not show he is rendered unable to physically or mentally secure or follow substantially gainful employment as a result of his service-connected disabilities. As indicated in the record, the Veteran reported a lengthy employment history at a glass container company as a machinist from 1999 to 2008. Furthermore, the Veteran reported being fired in March 2008 due to a worker's compensation conflict. The Veteran also reported that although his right knee was bothering him at work, he was able to manage. Furthermore, the Veteran self-reported that he did not seek to obtain employment after injuring his knee at his job in 2008. Overall, the record indicates that the Veteran's post-service work experience is such that the impairment caused by his service-connected disabilities would not prevent him from securing and following substantially gainful employment for the time in question. Moreover, there is no evidence in the record to support a finding that the Veteran's service connected disorders symptoms are manifested by total social or occupational impairment. As the records shows, the Veteran's right knee present some functional and occupational limitations which preclude the Veteran from physically laborious job functions, there is no indication that the Veteran cannot perform light sedentary work of a non-laborious nature. Moreover, there is no indication in the record that the Veteran's post-traumatic headaches or TBI present any significant functional or occupational limitations. The Board does acknowledge the Veteran's self-reporting of syncope episodes; however, there is no evidence in the record to support a finding that the Veteran has been diagnosed with chronic syncope episodes or experiencing prostrating attacks. As indicated in the record, the Veteran's non-service connected disorders are primarily responsible for his receipt of his SSA disability benefits. Moreover, the Board has determined that the Veteran's employment impairment for this time is due to factors other than his service-connected disorders such as his low back pain and obesity. The Board has also determined that nothing suggests symptoms outside the norm for rating the service connected disorders during the entire period on appeal. Moreover, the evidence of record does not reveal that he presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization due to his service connected disorder so as to render impractical the application of extra-schedular consideration for his service connected disabilities. Although the Veteran has been rendered unable to obtain or maintain substantially gainful employment this is primarily due to his non-service connected low back disorders and obesity. As noted above, entitlement to a TDIU is warranted under 38 C.F.R. § 4.16 (b) regardless of the Veteran's disability ratings where the service-connected disabilities alone render him unemployable. The Board cannot grant a total disability rating based on individual unemployability under 38 C.F.R. § 4.16 (b) in the first instance, but must consider whether a remand for the AOJ to refer the case to the Director of Compensation Service is warranted. Bowling v. Principi, 15 Vet. App. 1, 10 (2001). For the following reasons, the Board finds that a remand to refer is not warranted. After a full review of the record, the Board finds that the evidence is against the Veteran's claim for TDIU. As discussed above, the pertinent evidence of record does not demonstrate that the Veteran's service connected disabilities, alone, are of sufficient severity to render him unable to secure or follow substantially gainful employment at any time during this appeal period. The Board would note that "[t]he percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual the Boards in civil occupations." 38 C.F.R. § 4.1. As a result, the Board concludes that the disability evaluations assigned to the Veteran's disorders under the VA Schedule for Rating Disabilities accurately reflect the Veteran's overall impairment to his earning capacity due to his service connected disabilities. MICHAEL D. LYON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Elliot. Harris 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.