Citation Nr: 22012017 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 16-11 317 DATE: March 2, 2022 ORDER Entitlement to a rating in excess of 10 percent from December 7, 2010 to September 25, 2020 for left foot plantar calluses is denied. Entitlement to a rating in excess of 10 percent from December 7, 2010 to September 25, 2020 for right foot plantar calluses is denied. Entitlement to a rating of 30 percent, but no higher, from September 25, 2020 to October 8, 2020, for bilateral acquired pes cavus, with metatarsalgia, hallus valgus, and plantar calluses (previously rated as plantar calluses, left foot and right foot) is granted. Entitlement to a rating of 30 percent, but no higher, from October 8, 2020 for bilateral acquired pes cavus, with metatarsalgia, hallus valgus, and plantar calluses is denied. Entitlement to a 100 percent rating for post-traumatic stress disorder (PTSD) is granted. Entitlement to total disability due to individual unemployability (TDIU), to the extent it is not otherwise moot, is denied. FINDINGS OF FACT 1. During the period prior to September 25, 2020, the Veteran's bilateral foot disability was characterized by painful callouses and mild hammer toes. 2. From September 25, 2020, the Veteran's bilateral foot disability was characterized by very painful callosities, some limitation of ankle dorsiflexion, severe foot pain that impaired the Veteran's ability to walk during flare-ups, and bilateral claw foot of the second, third, and fourth toes. 3. The Veteran's PTSD has manifested in total occupational and social impairment. 4. The evidence of record indicates that the Veteran's bilateral foot disability alone does not prevent him from securing and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent from December 7, 2010 to September 25, 2020 for left foot plantar calluses have not been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.3, 4.7, Diagnostic Code (DC) 5284 (2021). 2. The criteria for entitlement to a rating in excess of 10 percent from December 7, 2010 to September 25, 2020 for right foot plantar calluses have not been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.3, 4.7, DC 5284 (2021). 3. The criteria for entitlement to a rating of 30 percent, but no higher, from September 25, 2020 to October 8, 2020, for bilateral acquired pes cavus, with metatarsalgia, hallus valgus, and plantar calluses (previously rated as plantar calluses, left foot and right foot) have been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.3, 4.7, DC 5278 (2021). 4. The criteria for entitlement to a rating of 30 percent, but no higher, from October 8, 2020 for bilateral acquired pes cavus, with metatarsalgia, hallus valgus, and plantar calluses have not been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.3, 4.7, DC 5278 (2021). 5. The criteria for entitlement to a rating of 100 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, DC 9411 (2021). 6. The criteria for entitlement to TDIU, to the extent that it is not otherwise moot, have not been met. 38 U.S.C. § 1155 (2018); 38 C.F.R. § 4.16 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1971 to February 1973. This matter came before the Board of Veterans Appeals (Board) on appeal from a January 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). A September 2018 Board decision remanded the issues on appeal for further development. The Board notes that a October 2020 rating decision discontinued the Veteran's separate ratings for left and right foot plantar calluses under diagnostic code (DC) 5284 as of October 8, 2020 and assigned a higher combined rating for bilateral acquired pes cavus under DC 5278 thereafter. Accordingly, the earlier ratings under DC 5284 remain in effect for the period from December 13, 2010 to October 8, 2020. The Board has characterized the issues accordingly. As higher ratings are assignable during this period and the Veteran is presumed to seek the maximum available benefit, they remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Because higher ratings are also assignable for the bilateral foot disability under DC 5284 from October 8, 2020, that issue remains on appeal. Id. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Individual disabilities are assigned separate diagnostic codes. See U.S.C. §1155; 38 C.F.R. § 4.1. When there is a question as to which of two evaluations applies, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for the rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 39 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A determination of whether a claimant is entitled to an extraschedular rating is a three-step inquiry. If the Board determines that (1) the schedular evaluation does not contemplate the claimant's level of disability and symptomatology, and (2) the disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization, then (3) the case must be referred to an authorized official to determine whether, to accord justice, an extra-schedular rating is warranted. Thun v. Peake, 22 Vet. App. 111, 115-116 (2008); 38 C.F.R. § 3.321. 1.-2. Entitlement to ratings in excess of 10 percent from December 7, 2010 to September 25, 2020 for left and right plantar calluses The Veteran contends that he is entitled to an increased rating for his bilateral foot disability. The Veteran is currently rated as 10 percent disabling under Diagnostic Code (DC) 5284 separately for each foot for the period from prior to September 25, 2020. As will be discussed in detail below, the Board finds that a rating in excess of 10 percent for each foot from December 7, 2010 to September 25, 2020 is not warranted. 38 C.F.R. §§ 4.7, DC 5284. During this period, each of the Veteran's feet is rated separately under DC 5284 for foot injuries. Under this DC, a 10 percent rating is assigned for moderate foot injuries, a 20 percent rating is assigned for moderately severe foot injuries, and a 30 percent rating is assigned for severe foot injuries. A note directs that the actual loss of use of the foot should be rated as 40 percent disabling. This means that, in order to qualify for a higher rating, the evidence would need to show that the Veteran's foot disability was at least moderately severe. The words "moderate," "moderately severe," and "severe" as used in the various Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence. 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. A January 2011 VA examination diagnosed the Veteran with bilateral plantar calluses. The Veteran reported intermittent foot pain at the callus sites, particularly with walking, that was alleviated with rest. The examiner noted normal appearing feet with mild hammertoe on each foot, mild bilateral arch collapse, and a toe range of motion reduced 50 percent with bilateral tender calluses. The examiner also opined that the Veteran's bilateral foot disability did not preclude employment. VA treatment notes from 2011 document treating for calluses of the feet. A February 2011 VA treatment note documented painful calluses on both feet with chronic pain. It noted that he was in a wheelchair and could ambulate with the assistance of Canadian sticks. An April 2011 VA treatment note documented that the provider performed reduction of painful callus legions under the fifth metatarsal heads of both feet. The provider prescribed urea cream and insoles. In a May 2012 VA Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, the examiner noted the Veteran's reports that he was regularly using a wheelchair, cane, and crutches, as well as experiencing frequent falls, difficulty walking, and weakness in his legs. He also reported dizziness, balance issues, and severe back pain limited his mobility, particularly when walking. However, the examiner did not specifically mention or link any of these findings or reports to the Veteran's feet, noting that only the Veteran's back pain and finger amputation restricted the listed activities and functions. As a result, the findings and reports in the examination are assigned no probative weight. A March 2013 VA examination diagnosed the Veteran with bilateral plantar calluses. The examiner noted the Veteran's statement that his feet hurt at times but did not stop him from walking. The examiner also found that the Veteran's calluses were stable and had no functional impact on his ability to work, though it was noted that the Veteran used assistive devices such as a wheelchair and crutches regularly. VA treatment records show that the Veteran was given a diabetic foot evaluation in July 2015. The provider noted minor abnormalities (calluses) of both feet, with normal sensation. The Veteran was assigned a normal foot risk. An August 2018 VA treatment note indicated that the Veteran requested help with the calluses on his feet. He was provided with salicylic acid plaster to cover the calluses. A June 2019 VA skin examination documented thick callouses on both great toes that covered the lateral aspect of both feet. The Veteran reported that his wife helped him by trimming them as much as she could, but that he still had trouble with them. The examiner did not find that these callouses resulted in any functional impairment that impacted his ability to work. A September 2019 VA examination diagnosed the Veteran with bilateral plantar calluses. The Veteran stated that he had sharp and achy pain that at times would make him lose his balance. The examiner reported that the Veteran had sharp pain and swelling during flare ups that made him unable to walk or stand for prolonged periods of time. He noted that the Veteran's pain, weakness, and incoordination impacted the Veteran's ability to stand, walk, and run. The examiner noted the regular use of shoe inserts. At the outset, the Board finds that the VA examinations are adequate for appellate review. There is no evidence that the examiners were not competent or credible, and as the reports are based on the Veteran's statements, in-person examinations and the examiners' observations, the Board finds they are entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 30205 (2008). The Veteran submitted multiple statements regarding the severity of his foot disability. In a January 2011 statement, he detailed that his feet limited his ability to stand or walk and impacted his balance. The Veteran's daughter submitted a statement in May 2012 to support his claim for aid and attendance that was later denied. She noted that the Veteran required assistance with the activities of daily living, including showering, meal preparation, and dressing due to chronic pain and instability that made movement difficult. In a November 2012 statement, the Veteran noted that he was using leg braces and a wheelchair. The Board notes that the Veteran and his daughter are competent to report lay-observable symptoms such as pain and the time of its onset and accords their statements significant probative weight. See Layno v. Brown, 6 Vet. App. 465, 470. Upon review of the above, the Board finds that the weight of the evidence shows that the severity of the Veteran's left and right foot disabilities during this period was appropriately categorized as moderate and rating in excess of 10 percent for each foot is not warranted. A review of the record prior to September 25, 2020 reveals a diagnosis of and treatment for bilateral plantar calluses. The January 2011 VA examination indicated mild hammertoes and bilateral painful calluses that were alleviated with rest. The March 2013, June 2019, and September 2019 VA examiners found only bilateral plantar callouses. The September 2019 VA examination documented only functional impairment with prolonged standing, walking, and running. No foot symptoms other than pain leading to a reduction in toe range of motion and mild hammertoes were noted in the treatment record during this period. The Veteran's lay statements and those of his daughter regarding his lack of mobility are noted. However, the Board also notes that the Veteran also had chronic pain in his lower back that significantly impacted his mobility during this period. Because their statements are unclear about the severity and impact the Veteran's foot pain was having on his mobility rather than other disabilities, their statements are assigned little probative weight. The March 2013 VA examiner documented the regular use of a wheelchair and assistive devices, but also found that the Veteran's foot pain did not prevent walking, which indicates foot symptoms that are not moderately severe or severe. Indeed, the weight of the probative evidence of record is persuasively against a finding that the Veteran's foot pain was of the severity that would require such assistance to walk prior to September 25, 2020 because the findings in the VA examinations outweigh the lay evidence of record regarding mobility. Therefore, because the competent evidence of record is against a finding that the Veteran's foot disability was of more than moderate severity during the period prior to September 25, 2020 and a rating above 10 percent for each foot is therefore not warranted. The Board also considered whether other DC's would be available or applicable by analogy. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). However, the Veteran did not have any additional diagnoses or symptoms beyond plantar calluses and mild hammertoes during this period. Under DC 5282 for hammertoes, the highest rating available would still be 10 percent, which would offer no benefit to the Veteran. There is no rating specifically applicable to plantar calluses that would offer additional benefit to the Veteran if rated analogously. Regarding a rating above 10 percent for the Veteran's left and right foot disabilities during the period prior to September 25, 2020, the evidence is not in approximate balance or nearly equal in Veteran's favor. See Lynch v. McDonough, 2021 U.S. App. LEXIS 37307, No. 2020-2067 (Fed. Cir., Dec. 17, 2021). As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim is denied. The Veteran raised the question of whether he is entitled to extraschedular compensation. See March 2016 substantive appeal. The evidence reflects that the Veteran's foot disabilities manifested in pain and moderate functional impairment result that impacted his ability to place weight on his feet or stand or walk. The criteria for DC 5284 are broad and all inclusive. Thus, there are no symptoms or severity of symptoms reflected in the record that are not considered by the rating criteria. As a result, referral for extraschedular consideration is not warranted. 3. Entitlement to ratings in excess of 10 percent for right and left foot calluses from September 25, 2020 to October 8, 2020; entitlement to a rating of 30 percent from October 8, 2020 for bilateral acquired pes cavus, with metatarsalgia, hallus valgus, and plantar calluses As noted above, the October 2020 rating decision discontinued the separate ratings for each of the Veteran's feet pursuant to DC 5284 and assigned a combined bilateral rating of 30 percent under DC 5278 from October 8, 2020. The Board finds that the Veteran was entitled to a rating of 30 percent, and no higher, for both of his feet combined from September 25, 2020 to October 8, 2020 for his bilateral foot disabilities. From October 8, 2020, a rating in excess of 30 percent is not warranted. 38 C.F.R. §§ 4.7, DC 5284, 5278. The VA treatment record is silent for any diagnosis, treatment, or reported symptoms related to a foot disability during this period. A September 2020 VA examination diagnosed the Veteran with bilateral metatarsalgia, left foot hallux valgus, bilateral acquired pes cavus, and bilateral plantar calluses. The examiner noted the Veteran was experiencing severe and sharp bilateral foot pain that made it difficult to walk during flare-ups, "crow" toes, and painful calluses. She also reported that the Veteran was using arch supports and cushions, as well as a wheelchair or crutches during flares, but no pain medication. The examiner opined that the Veteran's hallux valgus of the left foot caused mild or moderate symptoms. She also found that the Veteran suffered from claw toes of the second, third, and fourth toes of the bilateral feet, as well as very painful callosities. While the examiner included a notation that the Veteran reported pain when pressure was applied to the bottom of both feet, the Veteran denied a diagnosis of plantar fasciitis and the examiner did not include such a diagnosis in her findings. The examiner also found some limitation of dorsiflexion at both ankles, though she did not find such limitation was to a right angle or that the Veteran suffered from a marked varus deformity. She found pain on examination in both feet that lead to functional loss. Finally, the examiner opined that the new diagnoses were a progression of the Veteran's previously service-connected bilateral plantar calluses diagnosis. At the outset, the Board finds that the VA examination is adequate for appellate review. There is no evidence that the examiner was not competent or credible, and as the reports are based on the Veteran's statements, in-person examinations and the examiners' observations, the Board finds they are entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 30205 (2008). Upon review of the above, the Board finds that the evidence shows that the Veteran's overall disability picture more nearly approximates the severity required of a 30 percent rating under DC 5278 for the period from September 25, 2020, which is the date of the September 2020 VA examination. Under the criteria for DC 5278, which is for claw foot (pes cavus), a 20 percent rating is warranted when the evidence shows unilateral symptoms of all toes tending to dorsiflexion, limitation of dorsiflexion at the ankle to a right angle, shortened plantar fascia, and marked tenderness under the metatarsal heads. A 30 percent is warranted if these symptoms are bilateral. A 30 percent rating can also be assigned for unilateral symptoms of marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, and a marked varus deformity. A 50 percent rating is assigned if these symptoms are bilateral. Unlike the previous VA examinations, the September 2020 examination showed very, sharp foot pain that made it difficult to walk during flare-ups, claw toes of the second, third and fourth toes of the feet, some limitation of ankle dorsiflexion, and very painful callosities. While the examination did not note that the limitation of the ankle's dorsiflexion was to a right angle, that the Veteran had shortened plantar fascia, or that all of the Veteran's toes tended to dorsiflexion, the examiner did note very painful callosities. This indicates that the Veteran is experiencing more than definite tenderness under the metatarsal heads as listed in the 10 percent criteria. The examiner found that this pain was so severe during flare-ups that the Veteran would occasionally require a wheelchair or crutches. When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. See 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). In consideration of the Veteran's pain severity, the limitation of motion of his ankle, and the level of noted functional impairment, the Board finds that the Veteran's disability more nearly approximated that of the 30 percent bilateral pes cavus rating criteria from the date of the September 25, 2020 VA examination. The Board finds that the weight of the evidence is against an evaluation above 30 percent for this period. As noted above, the Veteran's bilateral feet disability has been characterized by severe foot pain and calluses, some limitation in ankle range of motion, mild to moderate left foot hallux valgus, and claw foot of the second, third, and fourth toes. These symptoms are all encompassed by the 30 percent rating. The evidence does not show that the Veteran's bilateral foot disability is of the severity contemplated by the 50 percent rating criteria. This rating criteria note the requirement for significant foot deformities, such as dropped forefoot, all toes hammer toes, and marked varus deformity. While the September 2020 VA examination noted very painful callosities and noted that the Veteran's pain during flare-ups occasionally required the use of a wheelchair or crutches, it did not note any significant deformities such as listed in the 50 percent rating criteria. The examiner did not find marked contraction of the plantar fascia, hammer toes of any toes, or marked varus deformity. The Board again considered the functional impairment created by the level of the Veteran's pain as reported by the Veteran and his daughter, as well as the September 2020 VA examiner. However, it does not find that this alone, without the presence of the other foot deformities, rises to the level contemplated by the 50 percent bilateral pes cavus rating criteria. The Board has also considered whether a higher rating is warranted under another potentially analogous code or whether the Veteran would be entitled to a separate rating under another diagnostic code. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). While the Veteran has been diagnosed with mild to moderate left foot hallux valgus, he has not required surgery to include the resection of the metatarsal head as required for a unilateral rating under DC 5280. Therefore, a rating under DC 5280 would not result in any additional benefit to the Veteran. The September 2020 examiner also diagnosed the Veteran with bilateral metatarsalgia. There are no explicit criteria for DC 5279. Because the Veteran is already being compensated for his bilateral foot painincluding pain from his metatarsalgiaand its resulting impairment pursuant to DC 5278, a separate rating under DC 5279 would result in prohibited pyramiding. 38 C.F.R. § 4.14. The record does not establish, and the Veteran does not allege, that he suffered from plantar fasciitis, flatfoot, weak foot, hammer toes, or other foot injuries during this period. Therefore, higher or separate ratings under DCs 5269, 5276, 5277, 5281, 5282, or 5283 respectively are not warranted. The Board has also considered the application of DC 5284 for "other" foot injuries, as the Veteran is service-connected for foot disabilities for which there is no DC. See Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019). The Veteran is being compensated for the existence of bilateral foot pain and the level of functional loss due to his pain pursuant to Code 5278. It would again be tantamount to pyramiding to award a separate rating under DC 5284 for the same symptomatology as contemplated and utilized in the required rating under DC 5278. Moreover, as previously discussed, the Veteran's bilateral symptomatology did not result in any foot deformity or symptoms other than pain during this period. Separate ratings pursuant to DC 5284 from September 25, 2020 are therefore not warranted. See Id.; see also Yancy v. McDonald, 27 Vet. App. 484 (2016). The Board therefore finds that no other DC is applicable, either separately or by analogy. Regarding a rating above 30 percent for the Veteran's foot disability, the evidence is not in approximate balance or nearly equal in Veteran's favor. See Lynch v. McDonough, 2021 U.S. App. LEXIS 37307, No. 2020-2067 (Fed. Cir., Dec. 17, 2021). As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim is denied. The Veteran raised the question of whether he is entitled to extraschedular compensation. See March 2016 substantive appeal. The evidence reflects that the Veteran's foot disabilities manifested in pain and functional impairment result that impacted his ability to place weight on his feet or stand or walk. The criteria for DC 5278 consider pain and limitation of motion. Thus, there are no symptoms or severity of symptoms reflected in the record that are not considered by the rating criteria. As a result, referral for extraschedular consideration is not warranted. 4. Entitlement to a rating in excess of 30 percent for PTSD The Veteran contends that he is entitled to a higher rating for his PTSD. The Veteran has been assigned a 30 percent rating from September 2007, with a temporary 100 percent rating due to hospitalization from September 2013 to November 2013. As will be discussed in detail below, the Board finds that a rating of 100 percent is warranted for the entire period on appeal, apart from the period where a temporary total rating has already been assigned. 38 C.F.R. §§ 4.7, 4.130, DC 9411. For psychiatric disabilities, ratings are assigned according to the manifestation of symptoms, but the use of the term "such as" in the General Rating Formula demonstrates that the symptoms after the phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Neither the number of symptoms nor the type of symptoms controls in determining whether the criteria for the next higher rating have been met. It is the effect of the symptoms, rather than the presence of symptoms, pertaining to the criteria for the next higher rating, that is determinative, and the Board must draw fact-based conclusions as to whether those symptoms, and their severity, frequency and duration, have caused the level of occupational and social impairment associated with a given rating. Bankhead v. Shulkin, 29 Vet. App. 10 (2017). The Board notes that the presence of suicidal ideation alone conceivably might cause occupational and social impairment with deficiencies in most areas, consistent with a 70 percent rating. Bankhead, 29 Vet. App. at 19. For the entire period on appeal, the Veteran has been rated under Diagnostic Code (DC) 9411 for PTSD, which is evaluated under the General Rating Formula for Mental Disorders. Under the DC, the criteria for a 30 percent rating are 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, mild memory loss (such as forgetting names, directions, recent events). The criteria for a 100 percent rating are 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 of others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. A January 2011 VA examination did not find sufficient evidence on examination to warrant a diagnosis of PTSD. While the examiner noted the Veteran's reports of in-service traumas, sleep impairment, nightmares, avoidance behaviors, social isolation, and depressed mood in the interview section, he did not note any impairment in thought process and communication. He reported that, if the Veteran was determined to be suffering from PTSD, his symptoms and impairment would be mild. The examiner stated that the Veteran likely suffered from other psychiatric conditions and that such conditions were not considered during the examination. An April 2011 VA treatment record noted that the Veteran's diagnosis remained unclear, and that the Veteran was minimally cooperative without showing overt signs of psychiatric illness. The provider did note that the Veteran reported seeing one of his previous assailants from a 1990 assault every time he came to the VA for care, which the provider noted as unlikely given the frequency of his visits. A July 2011 VA treatment record noted the presence of multiple PTSD symptoms, to include sleep issues with frequent nightmares, irritable mood, intrusive memories when trauma triggers were present, and isolation except around his family. The Veteran denied suicidal and homicidal ideations, as well as auditory and visual hallucinations. He was also positive on both PTSD and depression screening. In June 2012, a VA treatment provider noted that the Veteran appeared to have impaired cognitive functioning with mumbling, difficulty completing sentences, and significant forgetfulness. The provider also noted anger, irritation, and difficulty in comprehension. By December 2012, the Veteran reported that he was still hearing voices that were no longer violent. He stated that his medications were helping and denied suicidal ideations or plans for self-harm. A February 2013 VA treatment note reports that the Veteran's mood was improved, but that the Veteran was vague when discussing his symptoms. The provider noted that depression, anger, and irritability appeared to be the current symptoms, and that the Veteran denied suicidal ideations, homicidal ideations, and audiovisual hallucinations. A March 2013 VA examination diagnosed the Veteran with PTSD, though she noted the Veteran met very few criteria. The examiner stated that the Veteran had no other mental disorders diagnosed. She also determined that the Veteran had a mental condition that was formally diagnosed but symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. In her clinical findings, the examiner noted that the Veteran did not know the day of his birth, social security number, or the number of his children. She also reported that the Veteran's wife and family members assisted him with his activities of daily living, medications, and finances. The examiner found that the Veteran's memory deficits made him incapable of managing his financial affairs. The examiner reported symptoms of nightmares, avoidance behaviors, depressed mood and diminished interest, irritability or outbursts of anger, hypervigilance, and impaired impulse control. While the examiner opined that the Veteran's memory deficits were not due to his PTSD, there was no explanation or finding of what was causing the impairment. In a July 2013 VA treatment record, the Veteran requested admission to a PTSD treatment program but was denied as the provider did not feel he met the diagnostic criteria for PTSD at that time. The Veteran continued to report nightmares related to his trauma, as well as anger and irritability. He denied suicidal ideations, homicidal ideations, and audiovisual hallucinations. The Veteran was hospitalized in September 2013, for which he is already receiving a temporary total rating. As discussed above, the Board is not disturbing this rating. However, it is including an analysis of the Veteran's reported symptoms to illustrate his evolving symptomology and functional impairment. At the time of his September 2013 hospitalization, the Veteran reported a history of poor impulse control with a history of aggression, nightmares, angry outbursts, avoidance, intrusive thoughts, social isolation, difficulty concentrating, and flashbacks. He did not report current suicidal or homicidal ideations, though he did endorse hearing auditory hallucinations since he was a teenager. His providers found his speech difficult to understand, with global impairment in orientation, working memory, delayed recall, and sustained attention. In October 2013, the VA treatment provider diagnosed him with PTSD and schizophrenia by history, also noting panic symptoms and severe depression. By the time of his November 2013 discharge, the Veteran reported good relationships with his family, denied psychiatric symptoms, as well as suicidal ideations or plans. In November 2014, the Veteran's VA treatment provider noted increased anger, frustration, and irritability with outbursts that included throwing paper at the provider. He endorsed difficulty sleeping, thoughts of harming himself and others, and throwing things. He denied plans for self-harm at the time. The provider noted that he was dysphoric and irritable with pressured, spontaneous speech and circumstantial thought process that required frequent redirection. In July 2015, the Veteran reported improved sleep with nightmares, improved social interaction, and continued isolation and avoidance behavior. In January 2018, the Veteran reported suicidal thoughts within the past week with no plans and endorsed a history of attempts "a couple of years ago." In May 2018, he reported nightmares and intrusive memories, without current suicidal ideations or homicidal ideations. A June 2019 VA examination reported only a diagnosis of PTSD, with no other diagnosis of a mental health disorder. The examiner found that the Veteran's PTSD resulted in occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. He noted that the Veteran often raised his voice in anger, that the Veteran was socially isolated beyond his family, was experiencing frequent nightmares and intrusive memories of his traumas and endorsed suicidal thoughts with a history of suicide attempts. The examiner also noted that the Veteran "sometimes plays Russian roulette." He listed the symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. A July 2019 VA treatment record notes that the Veteran was tangential and difficult to understand, with persistent distrust of the VA system. The Veteran noted continued difficulty with sleep and nightmares, as well as anger, depression, and auditory hallucinations. An August 2019 treatment note documented that the Veteran reported hearing voices inside and outside his head since he was a teenager, though he did not report any current suicidal or homicidal ideations. An October 2020 treatment record documented chronic suicidal ideations without plan or intent, with an intermittent passive death wish and general thoughts to harm an unspecified individual the Veteran believed stole from him. The provider noted that the Veteran's mood was stabilized with medication, though he continued to experience irritability and auditory hallucinations. At the outset, the Board finds that the VA examinations are adequate for appellate review. There is no evidence that the examiners were not competent or credible, and as the reports are based on the Veteran's statements, in-person examinations and the examiners' observations, the Board finds they are entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 30205 (2008). The Veteran has submitted multiple statements during the period on appeal. In January 2011, the Veteran submitted a statement in which he noted that his PTSD symptoms were worsening to the point that they impacted his daily living, relations with others, concentration, sleep, and stress. The Veteran's daughter submitted a statement in May 2012 in which she related that the Veteran's family, particularly his wife, were aiding him with showering, meal preparation, medication management, dressing, and sleeping. She particularly noted memory issues and a loss of interest in activities he previously enjoyed. In May 2013, the Veteran submitted a statement in which he agreed that he was incompetent for VA financial purposes and that his wife was already handling his Social Security finances. The Board notes that the Veteran and his daughter are competent to report their activities of daily living and lay-observable symptoms such as pain or memory loss and accords their statements significant probative weight. See Layno v. Brown, 6 Vet. App. 465, 470. Upon review of the above, the Board finds that the Veteran's overall disability picture more nearly approximated the severity required for a 100 percent rating for the entire period on appeal. That is, the weight of the evidence indicated that the Veteran's PTSD caused 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 of others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. The Board finds that, during the period on appeal, the Veteran's PTSD was characterized by chronic sleep impairment, depression, isolation and avoidance behaviors, suicidal ideations, impaired impulse control, persistent danger of self-harm, intrusive memories, persistent delusions, impairment in communication, intermittent inability to perform activities of daily living, and significant memory loss. The Veteran regularly reported sleep impairment and nightmares throughout the period on appeal. The June 2019 VA examination noted that the Veteran was socially isolated beyond immediate family and that he continued to experience depression, anxiety, chronic sleep impairment, suspiciousness, and disturbances of motivation and mood. Significantly, the June 2019 VA examination also found that the Veteran was still experiencing suicidal ideations and "sometimes played Russian roulette." The Veteran reported continued anger and irritability. While there is no evidence in the record of any suicidal or homicidal attempts during the period on appeal, the Veteran's impaired impulse control, suicidal ideations, and risk-seeking behavior indicate a persistent danger of self-harm. The treatment records from October 2020 documented that the Veteran was still experiencing audiovisual hallucinations and intrusive memories, as well. These symptoms are similar to the persistent delusions in the 100 percent rating criteria. The evidence also indicates that the Veteran suffered from communication and memory deficits during this period. As recently as July 2019, the Veteran's providers were noting that the Veteran's speech was tangential and difficult to understand, and that he required frequent redirection during conversation. The March 2013 noted significant memory impairments, as the Veteran could not remember his own birthdate, social security number, or the number of his children. The examiner reported that the Veteran was receiving assistance from his family, particularly his wife, in his activities of daily living, medications, and financial affairs. The Board notes that the Veteran was found not to be competent in managing his finances for VA purposes in March 2014. The statements of the Veteran and his family members also support the finding of the March 2013 examination that the Veteran needed significant assistance in managing his daily affairs, medications, and finances. Because the March 2013 VA examiner did not explain the cause of the Veteran's memory problems if other than his PTSD, and the Veteran has not been diagnosed by VA examiners of a psychological disorder other than PTSD, the Board will attribute the Veteran's memory impairment to his PTSD. See Mittleider v. West, 11 Vet. App. 181 (1998). The competent evidence persuasively showed that, during the entire period on appeal, the Veteran's overall disability picture more nearly approximated the frequency, severity, or duration of psychiatric symptoms required for a 100 percent disability evaluation based on total occupational and social impairment. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. A rating of 100 percent is therefore warranted for the entire period on appeal. 5. Entitlement to total disability due to individual unemployability (TDIU) The Veteran contends that he is unable to work due to his service-connected PTSD and foot disabilities. See December 2010 VA Form 21-8940. The Board notes that the Veteran now has a single disability rated 100 percent for PTSD during the entire period on appeal. As a result, TDIU is moot except to the extent that it could be the basis of an award of special monthly compensation (SMC) at the housebound rate. SMC at the housebound rate is payable if a veteran has a single service-connected disability rated at 100 percent and has an additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). A TDIU rating based on a single disability is permitted to satisfy the statutory requirement of a 100 percent rating. Bradley v. Peake, 22 Vet. App. 280, 293 (2008). The analysis will therefore be limited as to whether one of the Veteran's disabilities other than PTSD alone prevent him from securing or following a substantially gainful occupation. TDIU may be assigned where the schedular rating is less than total when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation due to service-connected disabilities. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. § 4.16(a). For the purposes of considering whether this threshold has been met, disabilities resulting from a common etiology are treated as one disability. Id. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, rating boards should submit to the Director, Compensation Service, for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the schedular percentage standards. The initial question for the Board is whether the Veteran meets the schedular threshold for consideration for TDIU. Apart from PTSD, the Veteran is service connected for a bilateral foot disability which pursuant to this decision is now rated at 10 percent for each foot from December 7, 2010 to September 25, 2020, and 30 percent together thereafter. The Veteran is also rated at 10 percent for tinnitus. For the period on appeal, these disabilities do not meet the schedular threshold for TDIU. The September 2018 Board remand referred the issue to the Director, Compensation Service for extraschedular consideration. In a June 2020 memorandum, the Director, Compensation Service, found that extraschedular TDIU for the period on appeal was not warranted, but the Board is not bound by that finding. The Board will therefore consider whether any of the Veteran's non-psychiatric service-connected disabilities solely rendered him unable to secure and maintain substantially gainful employment during the relevant period on an extraschedular basis. This involves consideration of two components: an economic component involving an occupation outside of a protected environment earning more than marginal income, and a non-economic component involving the Veteran's ability to secure and follow such employment. See Ray v. Wilkie, 31 Vet. App. 58 (2019). VA may consider the Veteran's level of education, special training, and previous work experience in making this determination, but may not consider age or the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Ferraro v. Derwinski, 1 Vet. App. (1991). Medical evidence describing the effect of each disability on the Veteran's occupational functioning is crucial to permit the Board to arrive at an assessment of employability. 38 C.F.R. § 4.1. However, the determination of whether service-connected disabilities are of sufficient severity to produce unemployability is ultimately the Board's to make. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Therefore, the Board will review the medical evidence in the context of the other evidence of record prior to reaching a conclusion regarding employability. When the evidence is in approximate balance in the veteran's favor or nearly equal regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Lynch v. McDonough, 2021 U.S. App. LEXIS 37307, No. 2020-2067 (Fed. Cir., Dec. 17, 2021). The Veteran submitted a VA 21-8940 application for TDIU in December 2010, accompanying the claim for the issues on appeal. He reported that he worked as a motor vehicle operator from 1983 to 1989 and that he was prevented from working due to his PTSD, feet, and back. He made no mention of tinnitus. The Veteran also reported that he had specialized education as a diesel mechanic. He submitted another VA Form 21-8940 in November 2013 in which he reported that he worked as a forklift operator from December 1980 to February 1986. The Veteran noted that he left his employment due to a back injury. A September 1990 VA 21-526 claim outside the period on appeal includes a notation from the Veteran that he last worked in February 1990 as a de-packer operator. In the March 2016 VA Form 9, the Veteran indicated that he was receiving benefits from the Social Security Administration (SSA). In May 1992, the SSA found the Veteran to be disabled under the criteria for this agency due to psychiatric and lumbar spine disabilities. The Veteran is not service connected for a back disability, and, as noted above, his psychiatric disability cannot be considered in this analysis as it is already rated as 100 percent disabling. Thus, the SSA finding is assigned no probative weight. A comprehensive overview of the medical evidence regarding the severity and functional impact of the Veteran's bilateral foot disability is included in the above section addressing his entitlement to an increased rating during the period on appeal. The Board incorporates it here by reference. Upon review of the record, the Board finds that the competent evidence shows that the Veteran is able to obtain and maintain substantially gainful employment even on consideration of the effects of his bilateral foot disability. The Veteran has reported that his feet interfered with his employment, and the evidence supports the conclusion that the Veteran functional limitations with walking and standing that would impact active or physical employment with such requirements. The September 2020 VA examination indicated that the Veteran was experiencing severe foot pain that made it difficult to walk during flares and required the occasional use of a wheelchair or crutches. The examiner noted that such symptoms made it difficult for the Veteran to walk. The Board therefore finds that the Veteran's foot disability would impact strenuous physical labor or work that would require long periods of standing or walking. However, the competent evidence does not indicate that his feet render him unable to perform all non-marginal employment. The Veteran has his GED certificate with additional trade school training. There is also no indication that the Veteran's foot disabilities limit his ability to sit or use his upper body to perform tasks such as reaching, grasping, and manipulating objects with his hands. The September 2019 VA examination found impairment only with prolonged standing, walking, or running. It did not note the use of any assistive devices besides shoe inserts. The September 2020 VA examination noted use of a wheelchair and crutches only occasionally during flares. The VA examinations did not find physical impairment beyond prolonged walking or standing due to the Veteran's foot disability. Because the Veteran's foot disabilities do not preclude employment wherein the Veteran could sit for long periods of time, TDIU is not warranted on the basis of the Veteran's service connection foot disabilities alone, regardless whether rated separate for each foot or rated together as one disability. The Board notes that the competent evidence of record does not show, and the Veteran has not alleged, that his tinnitus prevents him from securing or maintaining a substantially gainful employment. Thus, TDIU is not warranted on the basis of the Veteran's tinnitus alone. In sum, given the Veteran's work experience and the impact of his physical disabilities during this period, the Board cannot say that the Veteran's foot disabilities or tinnitus alone prevent him from obtaining or maintaining substantially gainful employment. Accordingly, to the extent that it is not otherwise moot, TDIU is not warranted. J. SANDLER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Bock 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.