Citation Nr: 22016219 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 13-07 477 DATE: March 21, 2022 ORDER Entitlement to a rating in excess of 30 percent for residuals of crush injury to the right heel with calcaneus fracture is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is granted. FINDINGS OF FACT 1. The Veteran's right foot disability has not been manifested by impairment compatible with loss of use of the foot. 2. The Veteran's combination of service-connected disabilities meets the schedular criteria for assignment of a TDIU and is reasonably shown to have precluded him from securing and following substantial gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 30 percent for residuals of crush injury to the right heel with calcaneus fracture have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284. 2. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1976 to November 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In May 2016, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the transcript is associated with the evidentiary record. In July 2016 and May 2020, the case was remanded for further development. The Board notes that the May 2020 remand included a claim for service connection for psychiatric disorder. That claim was subsequently granted by a January 2022 rating decision and is no longer on appeal. Also, the instant appeal concerns only the orthopedic manifestations of the Veteran's service-connected right foot disability. Notably, a separate 10 percent rating for scar of the right foot was assigned by a March 2020 rating decision and this rating was increased to 20 percent by a January 2022 rating decision. However, the rating for this disability is not on appeal before the Board and the Veteran has not expressed disagreement with rating actions for this disability. 1. Entitlement to a rating in excess of 30 percent for residuals of crush injury to the right heel with calcaneus fracture. Service connection for residuals of crush injury to the right heel was granted by a March 1978 rating decision. A 10 percent rating was assigned effective November 10, 1977. In a February 2000 rating decision, the rating was increased to 20 percent effective October 25, 1999 and in a September 2002 rating decision, the rating was increased to 30 percent effective June 24, 2002. In February 2011, the Veteran sought an increased rating. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The Veteran's service-connected residuals of right heel crush injury are rated as 30 percent disabling under Diagnostic Code (Code) 5284. Under this Code, a 10 percent rating is warranted for moderate other foot injuries. A 20 percent rating is warranted for moderately severe other foot injuries. A 30 percent rating is warranted for severe other foot injuries. A Note to Diagnostic Code 5284 instructs that a maximum rating of 40 percent is available if there is actual loss of use of the foot. 38 C.F.R. § 4.71a, Code 5284. According to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension." See www.merriam-webster.com/dictionary/moderate. "Severe" means "of a great degree." See www.merriam-webster.com/dictionary/severe. Although loss of use of the foot is not defined under 38 C.F.R. § 4.71(a), for purposes of special monthly compensation under 38 C.F.R. § 4.63, loss of use of a foot will be held to exist when no effective function remains other than that which would be equally well served by an amputation with prosthetic. The determination should be made on the basis of the actual remaining function, such as the ability to balance, or propel the self forward. Medical evidence pertinent to the Veteran's claim for increase includes compensation and pension examinations, VA treatment records and private treatment records. The Veteran underwent examinations, which assessed the current severity of his right foot disability in May 2011, September 2017, January 2020, November 2021, and January 2022. At a May 2011 VA examination, it was noted that the Veteran's crush injury in service had involved fracture of the calcaneus (i.e. heel) and fracture blister of a wound to the right heel. The Veteran reported 7/10 pain level increasing to 10/10 pain level when he experienced a flare-up, which occurred twice per week and lasted all day. He noted that the flare-ups were caused by walking up to 15 minutes or 50 feet and were relieved with elevation, sitting, and resting. He indicated that pain medication had not given him any relief and that he had not had any therapy or pain injections. Physical examination showed that the toes and ankles were up and downgoing and there was neutral hindfoot alignment of the heel. The heel cord was in a neutral alignment in a standing position. The Veteran had hypersensitivity paresthesias of the L5-S1 dermatome, over his medial, lateral, and posterior foot. The Veteran was exquisitely tender over and hypersensitive over a 3cm x 2cm x 5mm deep indentation over the medial heel with hypertrophic callus formation. He was tender to palpation along the heel and he had painful foot motion with subtalar inversion and eversion of the foot. The examiner commented that the Veteran did have pain with physical exam and range of motion testing and it was conceivable he might have further limitations with respect to decreases in range of motion and function and pain in the future particularly after he had been on his feet all day. At a September 2017 VA contract examination, Veteran reported not being able to have a good quality of life or to be mobile due to his right heel pain worsening and causing him to be isolated at home. He indicated that he was unable to bear weight much on the right heel or get around and that numbness and tingling to the right heel was constant. He also reported numbness and tingling to the left foot and that he had to use crutches to ambulate. He rated his pain as an 8 on a scale of 1 to 10. He reported the pain as being so severe that he wanted to cut his foot off to stop the pain. He also noted that he was taking gabapentin for pain, 100 mg in the morning and an additional 300 mg as needed. The Veteran did not report flare-ups. On examination, there was pain on dorsiflexion and plantar flexion of the foot, both laterally and medially and there was evidence of pain on weight-bearing. It was noted that the Veteran was constantly using crutches due to the residuals of the crush injury to the right heel. The examiner found that the Veteran's foot condition did not result in functional impairment such that no effective function of the right foot remained other than that which would be equally well-served by an amputation with prosthesis. The examiner noted that the Veteran reported being unable to work due to right heel pain. At a January 2020 VA contract examination, the Veteran reported increased pain/tenderness in the right foot with weight bearing. He characterized the pain as severe, constant, and throbbing along with severe, sharp stabbing pain and an increased level of tenderness with flare-ups. He indicated that he had a severe antalgic gait requiring a walker and noting aching pain in the toes of the right foot with throbbing pain of the big toe at times. He reported that he was taking gabapentin and Ibuprofen for pain and inflammation. He described his functional loss as difficulty walking or standing more than a few minutes without rest, and difficulty walking over 20 yards without rest, and noted that he ambulated with a walker. The examiner described the Veteran's foot disability as residuals of crush injury to the right heel, calcaneus fracture with scar, severe, and degenerative arthritis of the right foot, moderate. The examiner indicated that the foot chronically compromised weight bearing. The examiner described the functional loss from the disability as pain on weight bearing and non-weight bearing, disturbance of locomotion, and interference with standing. The examiner also noted that the Veteran had difficulty walking or standing over a few minutes without rest and difficulty walking over 20 yards without rest. He also noted that the Veteran made regular use of a walker, had increased pain on weight bearing, and constant pain at rest. The examiner found that the Veteran's functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner commented that the Veteran had chronic altered weight bearing of the right foot due to severe heel pain and tenderness causing increased stress on the metatarsal region and toes likely leading to chronic inflammation. An X-ray revealed degenerative arthritis of the right foot which was likely caused by the altered weight bearing placing increased stress on metatarsal and interphalangeal joints. At a November 2021 VA contract examination, the Veteran reported current pain to his right foot. He indicated he was not able to get around due to his heel and he has gained up to 400 pounds and needed to lose weight for a hip replacement. He reported that he was not receiving any current treatment. The examiner noted that the impact of the condition was the Veteran had pain with walking and needed to be careful as if he stepped on something, he would fall at times, would need help getting back up and would suffer severe pain. The examiner noted that there was no pain at rest or on the day of the examination. The Veteran complained of pain triggered by prolonged/ excessive/repetitive/persistent use that was relieved by rest. He did not report flare-ups. The examiner found that the disability of the Veteran's foot was moderately severe and that it did chronically compromise weight-bearing. Concerning functional loss, the examiner found that the Veteran had less movement than normal. The Veteran reported regular use of a cane and walker. The examiner determined that the Veteran did not have functional impairment of the right foot such that no effective function remained other than that which would be equally served by amputation with the prothesis. The examiner found that the functional impact of the foot disability was that the Veteran was unable to sit/stand/walk for long on any surface and was unable to jog/jump/hike/climb/run/sprint. In a December 2021 medical opinion, the November 2021 VA contract examiner found that the Veteran had no true right ankle condition other than the irregular scar noted to be of the medial malleolus, which was directly related to the in-service calcaneal injury. Therefore, it was less likely than not that the Veteran had an additional ankle condition secondary to the crushed heel injury in service. The examiner noted that degenerative changes of the foot on imaging, other than the calcaneal spurring, were not likely to be secondary to the crush injury and were likely naturally occurring. The examiner found that the calcaneal spurring itself did not represent arthritis but was a change due to the chronic inflammation associated with the prior injury. At a January 2022 VA contract examination, the Veteran reported constant dull aching pains in the right foot and heel while at rest that became sharp with activity. He indicated trouble walking, sitting, and standing for long periods at a time and reported a pain level of 8/10. He noted that he was unable to exercise or do any activities that required the use of his right foot and right heel. The examiner found that the Veteran had plantar fasciitis and hallux valgus of the right foot. He assessed the hallux valgus as producing mild or moderate symptoms and noted that the big toe had limited motion. The Veteran also reported flare-ups with walking and standing that were daily, lasted for a few minutes and involved sharp pains. An alleviating factor for this was rest. Physical examination showed that the right foot was dressed in a stockinette, cast padding, and Coban. Upon removal of the dressing, the right foot was noted to be red and swollen with a decreased range of motion. X-ray was noted to show minimal degenerative changes of the first metatarsophalangeal (MTP) joint and interphalangeal joints and right foot calcaneal spur. The Veteran complained of pain when the right foot and heel were palpated, and he had decreased range of motion to the right big toe. The examiner found that the Veteran had moderately severe disability of the right foot, which chronically compromised weight bearing. The examiner noted functional loss characterized by less movement than normal, swelling, disturbance of locomotion, interference with sitting, interference with standing, pain, and weakness. The examiner noted that the evidence did suggest functional loss due to pain, which significantly limited functional ability during flare-ups or over repeated use over time, again finding that the Veteran had trouble walking, sitting, and standing for long periods at a time and inability to exercise or do any activities that required the use of his right foot and right heel. The examiner also noted pain on passive motion, active motion, weight-bearing, non-weight-bearing and on rest/non-movement, noting again that the Veteran reported constant dull aching pains in the right foot and heel while at rest that became sharp with activity; trouble walking, sitting, and standing for long periods at a time; and an inability to exercise or do any activities that required the use of his right foot and right heel. The examiner indicated that the Veteran used a walking boot that did not fit properly on occasion as an assistive device. The examiner found that the Veteran's condition did not cause functional impairment to the level that no effective function remained other than that which would be equally well-served by an amputation with prosthesis. Upon review of prior X-ray findings, the examiner commented that the abnormal findings led to a diagnosis of right foot post-traumatic arthritis, residuals of a crush injury to the right heel, calcaneus fracture with a scar, plantar fasciitis, hallux valgus, and right foot calcaneal spur due to repeated stress on the right heel, use, wear, and tear on weight-bearing. The examiner concluded that due to the diagnosis of right foot post-traumatic arthritis, residuals of a crush injury to the right heel, calcaneus fracture with a scar, plantar fasciitis, hallux valgus, and right foot calcaneal spur, the Veteran had trouble walking, sitting, and standing for long periods at a time and could not do any activities that require the use of his right foot and right heel. Additionally, the examiner found that the diagnosis of residuals of a crush injury to the right heel, calcaneus fracture with scar had progressed to right foot post-traumatic arthritis from repeated use with wear, and tear on weight-bearing causing degenerative changes in the right foot. The plantar fasciitis was due to the residuals of the crush injury to the right heel and calcaneus fracture with a scar from repeated stress on the heel bone. Also, hallux valgus developed because of the Veteran's arthritis in the right foot. Moreover, the examiner commented that the Veteran used a cane and walker that he purchased for his right foot and heel pain. The examiner found that the Veteran's calcaneal spur developed from the diagnosis of residuals of a crush injury to the right heel, calcaneus fracture, with a scar, from repeated stress on the heel bone. VA medical records, private medical records and Social Security Administration (SSA) records generally acknowledge the Veteran's service-connected foot disability with symptoms that included arthralgias, joint pain, difficulty walking, limitations on standing, inability to sit for long periods of time, decreased sensation and use of assistive devices, including a cane. He has been noted to take medications for foot pain, including Ibuprofen, Gabapentin and Diclofenac. See e.g. August 2011 private physician's statement of disability for purposes of discharge of student loan debt, May 2017 private treatment record, and May 2019 private treatment record. The Veteran has also reported the presence of significant foot symptomatology, including chronic pain, swelling after sitting, difficulty bearing weight, trouble walking, having to use his left leg for support, the need to use crutches to move around outside his home, the need to grab ahold of things when he is moving around his house to help him balance, and losing his balance and falling in his house approximately 2 to 3 times per week (per his May 2016 hearing testimony). See e.g. August 2011 statement, May 2016 hearing testimony and May 2016 statement. Although the above summarized evidence indicates that the Veteran suffers from significant right foot impairment, the right foot disability is not shown to result in loss of use of the foot (i.e. impairment resulting in no effective function other than that which would be equally well served by an amputation with prosthetic). In this regard, the September 2017, January 2020, November 2021, and January 2022 examiners all found that the Veteran's foot condition did not result in functional impairment such that no effective function of the right foot remained other than that which would be equally well-served by an amputation with prosthesis. These determinations were made after full consideration of the functional impairment from the Veteran's foot disability, including consideration of the Veteran's subjective reports and physical examination findings, taking into account the impact on function by repetitive use and flare-ups. There is also no medical opinion to the contrary (i.e. an opinion tending to indicate that the Veteran does have this level of loss of use) and neither the Veteran nor his attorney has specifically alleged that this is the case. Consequently, the weight of the evidence is against assigning a higher 40 percent rating under Code 5284 based on loss of use of the foot at any time during the appeal period. 38 C.F.R. § 4.71a. The Board notes that the January 2022 VA contract examiner found that the Veteran's underlying crush injury residuals had progressed to involve plantar fasciitis and post-traumatic arthritis, which in turn had resulted in hallux valgus. Thus, the post-traumatic arthritis, hallux valgus and plantar fasciitis are reasonably shown to be part of the underlying service-connected disability. However, as alluded to above, the arthritis, plantar fasciitis and hallux valgus combined with the other existing residuals of the crush injury are not shown to result impairment compatible with loss of use of the foot, which is what is required to warrant an even higher, 40 percent rating for the foot disability. Consequently, the foot disability as a whole still warrants a 30 percent rating under Code 5284. Also, although Code 5280 does provide for a 10 percent rating for hallux valgus when the impairment is severe or requires resection of the metatarsal head of the big toe, neither of these situations is present in the Veteran's case. Consequently, a separate rating under Code 5280 is not warranted. Id. Moreover, the Veteran is already assigned the existing 30 percent rating for the severe right foot disability, along with a 20 percent rating for scar of the right heel from January 4, 2022, the date of the VA contract examination establishing the presence of hallux valgus. Under the amputation rule, the combined rating for disability of an extremity shall not exceed the rating for amputation at the elective level were amputation to be performed. 38 C.F.R. § 4.68. Notably, amputation of the lower leg, permitting prosthesis, warrants a 40 percent rating under Code 5166. Id. Were the Veteran to be assigned another 10 percent disability rating for his right foot disability from January 4, 2022 (when the above mentioned additional disability, including hallux valgus, was found by the VA contract examiner), in addition to the already assigned 30 percent rating for residuals of crush injury and 20 percent rating for scar, his combined rating for disability of the lower leg from January 4, 2022 would exceed 40 percent (e.g. under 38 C.F.R. § 4.25, the combined ratings table, the combined rating would equal 50 percent), which impermissibly violates the amputation rule. 38 C.F.R. §§ 4.68, 4.71a, Code 5166. The Board also notes that recent evidence indicates the Veteran has impairment of the right ankle. See e.g. January 4, 2022 VA contract examination with diagnosis of right ankle strain. However, the Veteran is not service connected for right ankle disability and a claim for service connection for such disability is not on appeal. Also, the evidence weighs against any current right ankle disability constituting a residual of the Veteran's in-service foot injury. In this regard, after a specific review of the record, a December 2021 VA contract physician opined that it was less likely than not that the Veteran had an additional ankle condition as a residual of his in-service heel crush injury, noting that there was no apparent injury to the ankle joint itself from the in-service injury. There is no medical opinion evidence of record to the contrary (i.e. an opinion tending to indicate that the Veteran does have right ankle disability as a residual of the service-connected right foot disability). Also, to the extent the Veteran may believe that such a relationship is present, as a layperson with no demonstrated medical expertise concerning the etiology of right ankle disability, this assertion may not be afforded any probative value. See e.g. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, considering all appropriate criteria, the evidence weighs persuasively against assignment of a rating in excess of 30 percent for the Veteran's service-connected right foot disability at any time during the appeal period. 2. Entitlement to a TDIU. The Veteran asserts that his service-connected disabilities render him unemployable and eligible for a TDIU award. A total disability rating for compensation based on individual unemployability (TDIU) may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). TDIU will be granted when the evidence shows that the veteran, due to his service-connected disabilities, is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. The Veteran's service-connected disabilities include borderline personality disorder, rated 50 percent disabling from April 25, 2011 and 70 percent disabling from July 8, 2021; residuals of crush injury to the right heel, rated 30 percent disabling; painful scar of the right heel, rated 10 percent disabling from January 9, 2020 and 20 percent disabling from January 4, 2022; and additional right heel scar, rated noncompensable. His combined disability rating is 70 percent effective April 25, 2011 and 80 percent effective July 8, 2021. Consequently, his service-connected disabilities meet the schedular requirements for assignment of TDIU. 38 C.F.R. § 4.16(a). VA Vocational Rehabilitation records show that the Veteran was assessed as not able to work or participate in an employment training program. The Veteran's psychiatric disability was cited as a primary reason for this, with his right foot disability also contributing to it. See e.g. November 2010 Vocational Rehabilitation Counselor's letter and July 2, 2010 initial Vocational Rehabilitation evaluation report. At a July 2011 VA psychiatric examination, the Veteran reported that he could not imagine himself as able to work due to problems interacting with others. He stated he would not be able to tolerate social interactions and would become irritated to the point that he feared he would act inappropriately, lashing out in anger. The examiner commented that the Veteran's depressive symptoms had been increasing over the recent past related to vocational, financial, and increasing chronic health conditions. In an August 2011 statement supporting the Veteran's application for discharge of his student loan debt due to total and permanent disability, a private physician indicated that the Veteran's chronic foot disability, depression, bipolar disorder, morbid obesity and dyspnea, made him unable to stand for prolonged periods, unable to walk significant distance and unable to sit for prolonged periods. The physician noted that the Veteran had difficulty standing and ambulating a significant time or distance. The physician concluded that the Veteran was unable to maintain gainful employment and unable to be in a social environment. In a July 2011 formal claim for TDIU, the Veteran reported that he worked as a truck driver throughout the 1990s and that he had not worked since 1999. He indicated that he obtained his GED and attended 2 years of community college, studying computer programming, but did not earn a degree. He noted that his Vocational Rehabilitation Counselor had determined that he was no longer eligible to continue in the program due to his impaired memory and pain from his service-connected disabilities. At the May 2016 Board hearing, the Veteran stated that his primary job since leaving service was as a truck driver. He indicated that he stopped working in that capacity because he could not sit for long periods without foot pain and swelling and that he had gone into truck driving because it was a job that had initially allowed him to be off his feet. At a July 2021 VA contract psychological evaluation, the psychologist found that the Veteran had been diagnosed with borderline personality disorder, which is characterized by a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, evidenced by efforts to avoid real or imagined abandonment, a pattern of unstable and intense interpersonal relationships, markedly unstable self-image or sense of self, impulsivity that is potentially self-damaging, suicidal behavior or threats, self-injurious behavior, affective instability due to marked reactivity of moods, chronic feelings of emptiness, inappropriate, intense anger or difficulty controlling anger, stress-related paranoid ideation or dissociative symptoms. The psychologist found that the level of impairment from this disability was best characterized as occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported that he left high school after trying twice to complete his 11th grade year. He stated that he got his GED while in the Army and was 17 years old when he joined. He noted that his specialty in service was tank crewman. The Veteran stated that he had various jobs after getting out of the Army. He reported that he drove a truck, did construction, carpentry, and welding and that he also received training in law enforcement, computer programing and diesel mechanics. He stated that he earned certificates but did not get his associate's degree. The Veteran reported that he had bouts of depression that 'last for an hour or two' and were triggered 'every time he tries to get out of his chair.' He noted that he was still able to drive and to walk, however he stated that he mostly stayed inside. He reported that he had an exercise bike, but it was hard to ride due to his arthritis. He indicated that he received information from a nutritionist, but it did not help him. The evaluating psychologist found that the Veteran's mental health symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, difficulty in understanding complex commands, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or work like setting. The above summarized evidence reasonably indicates that the Veteran's service-connected disabilities considered in conjunction with his prior work history and educational level, have rendered him unable to secure or follow a substantial gainful occupation due to the combination of his service-connected psychiatric disorder and right foot disability. In this regard, the VA Vocational Rehabilitation records show that the Veteran was assessed as not able to work or participate in an employment training program, citing a primary contribution from his psychiatric disability along with additional contribution from his right foot disability. Similarly, the subsequent compensation and pension examinations pertaining to the right foot show a highly significant level of impairment and the Veteran has reported that the disability prevented him from continuing to work as a truck driver (e.g. his foot would swell and become very painful upon sitting for an extended period of time). Also, the July 2021 VA contract examiner assessed the Veteran as having severe psychiatric impairment, which included severe impairment in occupational functioning reflected by symptoms that included mild memory loss, impairment of short and long term memory, flattened affect, difficulty in understanding complex commands, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances, including work or work like setting. Additionally, the evidence reasonably indicates that the severe impact of the psychiatric disorder on the Veteran's ability to secure or follow a substantial gainful employment has been relatively consistent during the appeal period. Notably, it appears that the Veteran does have some other disability impacting employability (e.g. low back problems). However, given that a consistently severe level of occupational impairment is established from the combination of the psychiatric disability and foot disability alone; given the Veteran's relatively limited level of education and work experience; and resolving any reasonable doubt in his favor, he is shown to have been unable to secure or follow a substantially gainful occupation due to his combination of service-connected disabilities during the entire appeal period. Accordingly, a TDIU award is warranted. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dan Brook, 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.