Citation Nr: 23012425 Decision Date: 03/01/23 Archive Date: 03/01/23 DOCKET NO. 05-03 082 DATE: March 1, 2023 ORDER Entitlement to service connection for a right shoulder disability, to include arthritis with bone spurs, is granted. Entitlement to service connection for left shoulder arthritis with bone spurs is granted. Entitlement to service connection for right knee arthritis with bone spurs as secondary to status post strain of the right knee is granted. Entitlement to service connection for right elbow arthritis with bone spurs as secondary to residuals of right radial head fracture is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) based on posttraumatic stress disorder (PTSD) with anxiety disorder not otherwise specified alone from June 15, 2017, to April 9, 2018, is granted. Entitlement to TDIU based on all service-connected disabilities from December 27, 2006, to June 14, 2017, is granted. Special monthly compensation based on housebound status since June 15, 2017, is granted. REMANDED Entitlement to service connection for arthritis of the back, to include as secondary to exposure to in-service environmental hazards during the Persian Gulf War and as secondary to service-connected disabilities, is remanded. Entitlement to service connection for bone spurs of the left knee, to include as secondary to exposure to in-service environmental hazards during the Persian Gulf War and as secondary to service-connected disabilities, is remanded. Entitlement to service connection for arthritis and bone spurs of the right hand, to include as secondary to exposure to in-service environmental hazards during the Persian Gulf War and as secondary to service-connected disabilities, is remanded. Entitlement to service connection for arthritis and bone spurs of the left hand, to include as secondary to exposure to in-service environmental hazards during the Persian Gulf War and as secondary to service-connected disabilities, is remanded. Entitlement to service connection for bone spurs of the left elbow, to include as secondary to exposure to in-service environmental hazards during the Persian Gulf War and as secondary to service-connected disabilities, is remanded. Entitlement to service connection for a right hip disability, to include arthritis and bone spurs of the left hand and as secondary to exposure to in-service environmental hazards during the Persian Gulf War and as secondary to service-connected disabilities, is remanded. Entitlement to service connection for a left hip disability, to include arthritis and bone spurs of the left hand and as secondary to exposure to in-service environmental hazards during the Persian Gulf War and as secondary to service-connected disabilities, is remanded. Entitlement to an initial disability rating in excess of 10 percent for residuals of a right radial head fracture is remanded. Entitlement to a disability rating in excess of 10 percent status post strain of the right knee is remanded. Entitlement to a disability rating in excess of 10 percent for degenerative joint disease, status post strain of the left knee is remanded. Entitlement to TDIU from April 30, 2009, to June 14, 2017, based on orthopedic disabilities alone or the psychiatric disorder alone for purposes of special monthly compensation based on housebound status is remanded. Entitlement to TDIU prior to December 27, 2006, based on all service-connected disabilities is remanded. Entitlement to special monthly compensation based on housebound status prior to June 15, 2017, is remanded. FINDINGS OF FACT 1. The evidence is in equipoise as to whether the right shoulder disability, to include arthritis with bone spurs, is related to the in-service right arm injury. 2. The evidence is in equipoise as to whether the left shoulder arthritis with bone spurs, is related to the in-service left shoulder injury. 3. The weight of evidence shows that the right knee arthritis with bone spurs was caused by the service-connected status post strain of the right knee. 4. The weight of evidence shows that the right elbow arthritis with bone spurs was caused by the service-connected residuals of right radial head fracture. 5. From June 15, 2017, to April 9, 2018, the Veteran was service connected for PTSD with anxiety disorder not otherwise specified. 6. From June 15, 2017, to April 9, 2018, PTSD with anxiety disorder not otherwise specified was rated 70 percent disabling. 7. From June 15, 2017, to April 9, 2018, the evidence is in equipoise as to whether Veteran's service-connected PTSD with anxiety disorder not otherwise specified alone rendered him unemployable from performing all forms of substantially gainful employment that are consistent with his education and occupational experience. 8. From April 30, 2009, to June 14, 2017, the Veteran was service connected for PTSD with anxiety disorder not otherwise specified, allergic rhinitis, a left shoulder disability, hypertension, bilateral knee disabilities, a right elbow disability, hearing loss, tinnitus, eczema, and left thigh scars. 9. From April 30, 2009, to June 14, 2017, these service-connected disabilities were rated 90 percent disabling with PTSD with anxiety disorder not otherwise specified being rated as 50 percent disabling. 10. From April 30, 2009, to June 14, 2017, the evidence is in equipoise as to whether Veteran's service-connected disabilities rendered him unemployable from performing all forms of substantially gainful employment that are consistent with his education and occupational experience. 11. From December 27, 2006, to April 29, 2009, the Veteran was service connected for allergic rhinitis, a left shoulder disability, hypertension, bilateral knee disabilities, a right elbow disability, hearing loss, tinnitus, and eczema. 12. From December 27, 2006, to April 29, 2009, these service-connected disabilities were rated 70 percent disabling with the orthopedic disabilities being rated 50 percent disabling. 13. From December 27, 2006, to April 29, 2009, the evidence is in equipoise as to whether Veteran's service-connected disabilities rendered him unemployable from performing all forms of substantially gainful employment that are consistent with his education and occupational experience. 14. Since April 10, 2018, the service-connected disabilities other than PTSD have been rated as 100 percent disabling and the service-connected PTSD with anxiety disorder not otherwise specified has been independently rated as 70 percent disabling. 15. From June 15, 2017, to April 9, 2018, the service-connected PTSD with anxiety disorder not otherwise specified is now rated as 100 percent disabling and the service-connected disabilities other than PTSD with anxiety disorder not otherwise specified have been independently rated as 70 percent disabling. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for a right shoulder disability, to include arthritis with bone spurs, have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2022). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for left shoulder arthritis with bone spurs have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for entitlement to service connection for right knee arthritis with bone spurs as secondary to status post strain of the right knee have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310 (2022). 4. The criteria for entitlement to service connection for right elbow arthritis with bone spurs as secondary to residuals of right radial head fracture have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. Resolving all reasonable doubt in the Veteran's favor, the criteria for entitlement to TDIU based on PTSD with anxiety disorder not otherwise specified alone from June 15, 2017, to April 9, 2018, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.155, 3.340, 3.341, 4.16, 4.19 (2022). 6. Resolving all reasonable doubt in the Veteran's favor, the criteria for entitlement to TDIU based on all service-connected disabilities from December 27, 2006, to June 14, 2017, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.155, 3.340, 3.341, 4.16, 4.19. 7. The criteria for special monthly compensation based on housebound status since June 15, 2017, have been met. 38 U.S.C. § 1114 (2012); 38 C.F.R. §§ 3.350, 4.25 (2022). REASONS AND BASES FOR FINDINGS AND CONCUSIONS The Veteran served on active duty from May 1969 to May 1994. These matters come before the Board of Veterans' Appeals (Board) on appeal from July 2004 (grant of service connection for a right elbow disability, denial of service connection for a right shoulder disability and a joint condition with pain, and denial of TDIU), April 2008 (denial of service connection for arthritis, bone spurs, a right hip disability, and a left hip disability), and August 2010 (denying increased ratings for bilateral knee disabilities) rating decisions of a Department of Veterans Affairs (VA) regional office (RO). In November 2009, the Veteran testified at a Travel Board hearing held at a RO before a Veterans Law Judge who is no longer employed at the Board. A transcript of that hearing has been associated with the electronic claims file. In July 2010, the Board granted service connection for a left shoulder disability and remanded for further development the claims of entitlement to service connection for a right shoulder disability; a joint condition with pain, to include arthritis; a right hip disability; a left hip disability; and bone spurs. The Board also remanded the issues of an increased rating for a right elbow disability and TDIU for further development. In July 2012, the Board remanded the issues of service connection for joint condition with pain, to include arthritis; a right shoulder disability; a left hip disability; a right hip disability; and bone spurs. The Board also remanded the issues of an increased rating for the right elbow disability and TDIU. In January 2016, the Veteran testified at a videoconference hearing held before a Veterans Law Judge who no longer serves in that position. A transcript of that hearing has been associated with the electronic claims file. In an August 2016 letter, the Board informed the Veteran that he had a right to a third hearing with a Veterans Law Judge on the issues that were addressed in both of the November 2009 and January 2016 hearings. Later in August 2016, the Veteran indicated that he did not want a third hearing. In a February 2017 remand, a three-judge panel that included the two judges who held the two hearings remanded the issues of entitlement to service connection for a right shoulder disability, a right hip disability, a left hip disability, bone spurs, and a joint disability, to include arthritis. The three-judge panel also remanded the issues of an increased rating for the right elbow disability and TDIU. In a February 2017 remand, the judge who held the January 2016 hearing remanded the issues of increased ratings for the bilateral knee disabilities. In an April 2018 letter, the Board informed the Veteran that the Veterans Law Judge who held the November 2009 hearing is no longer employed at the Board. The Board afforded the Veteran another opportunity for a hearing. Later in April 2018, the Veteran indicated that he did not want another hearing. In a May 2018 decision signed by the Veterans Law Judge who held the January 2016 hearing, the Board remanded the issues of entitlement to service connection for a right shoulder disability, a right hip disability, a left hip disability, bone spurs, and a joint disability, to include arthritis. The Board also remanded the issues of increased ratings for the right elbow disability and the bilateral knee disabilities as well as TDIU. In an April 2020 letter, the Board informed the Veteran that he would be advised by the Board concerning his request for a hearing. In a September 2020 letter, the Board informed the Veteran that he had elected an in-person Travel Board hearing with a Veterans Law Judge. In an October 2020 memorandum, the Board noted that a hearing had already been conducted in the Veteran's appeal. In January 2023, the Board informed the Veteran that the Veterans Law Judge who conducted the January 2016 hearing is no longer available to participate in his appeal. The Board afforded the Veteran another opportunity for a hearing and requested that he respond within 30 days. The Board indicated that if the Veteran did not respond within 30 days, the Board will assume that the Veteran does not want another hearing. The Veteran did not respond within 30 days. Therefore, no further development with regard to a hearing is necessary. In the July 2010 remand, the Board ordered development on whether any disability is secondary to service-connected disabilities. In a May 2012 written brief presentation, the former representative indicated that the Veteran is claiming the joint pain as secondary to Persian Gulf War service. In a February 2017 three-judge-panel remand, the Board noted that the Veteran is claiming service connection for arthritis in the shoulders, hands, hips, and right knee and for bone spurs in the knees, right elbow, shoulders, fingers, and hips. In a December 2006 statement, the Veteran indicated that he was claiming service connection for bone spurs of the elbows. In a November 2015 statement, the representative argued that the Veteran is claiming service connection for arthritis of the back. Therefore, the issues of entitlement to service connection for bone spurs of the left elbow and arthritis of the back before the Board. In light of the above, the service connection issues are as stated on the first two pages of these decision. The Veteran's service-connected disabilities have been rated 100 percent disabling since April 10, 2018. In years past, if a veteran received a 100 percent schedular rating for his service-connected disability, the issue of entitlement to a TDIU became moot since a veteran could not have a 100 percent schedular rating while concurrently having a TDIU. 38 C.F.R. § 4.16 (a) (2022); VAOPGCPREC 6-99 (June 7, 1999); 64 Fed. Reg. 52,735 (1999). Nonetheless, in view of the decision of the United States Court of Veterans Appeals (the Court) in Bradley v. Peake, 22 Vet. App. 280, 294 (2008), which took a position contrary to the one reached in the Office of General Counsel precedent opinion, the General Counsel took action to withdraw that prior opinion. Although no additional disability compensation may be paid when a total schedular disability rating is already in effect, the Court's decision in Bradley recognizes that a separate award of a TDIU predicated on a single disability may form the basis for an award of special monthly compensation based on housebound status. The Board observes that VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008) (finding that special monthly compensation "benefits are to be accorded when a Veteran becomes eligible without need for a separate claim" and remanding, pursuant to VA's duty to maximize benefits, for VA to determine whether the Veteran's posttraumatic stress disorder, rated 70 percent disabling, would entitle him to a TDIU and, therefore, to special monthly compensation). Thus, the issue of entitlement to special monthly compensation based on housebound status is before the Board at this time. As noted below, the Board is granting special monthly compensation based on housebound status since April 10, 2018, based on the current schedular ratings. Therefore, the Board does not have to consider whether TDIU since April 10, 2018, is warranted based on all service-connected disabilities or some service-connected disabilities. For the period from June 15, 2017, to April 9, 2018, the Board is granting TDIU based on PTSD with anxiety disorder not otherwise specified alone because a grant of TDIU on that disability alone warrants a grant of special monthly compensation based on housebound status. The Board is granting TDIU from April 30, 2009, to June 14, 2017, based on all service-connected disabilities because the Veteran does not currently have a single service-connected disability that meets the criteria for consideration under 38 C.F.R. § 4.16(a) (2022) during that time period. The Veteran, however, does meet the criteria for consideration under 38 C.F.R. § 4.16(a) based on all service-connected disabilities. The Board, however, is remanding the issue of TDIU for that time period based on the orthopedic disabilities alone or the psychiatric disorder alone for purposes of special monthly compensation based on housebound status because of the potential eligibility for special monthly compensation for that time period if TDIU was granted during that time period based on the orthopedic disabilities alone or the psychiatric disorder alone. Prior to April 30, 2009, the Veteran does not currently meet the criteria for consideration under 38 C.F.R. § 4.16(a). The Board is remanding TDIU prior to April 30, 2009, for further development. Service Connection 1. Entitlement to service connection for a right shoulder disability Governing law and regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Notwithstanding the above, service connection may be granted for disability shown after service, when all the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303(a). To establish service connection for a claimed disorder, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Analysis As for Hickson element (1), current disability, a December 2005 VA examination report reflects a diagnosis of status post strain of the right shoulder, partial tear of rotator cuff. X-rays taken in conjunction with that examination reveal arthritic changes of the acromioclavicular joint with subacromial spurring. A June 2015 VA examination report shows diagnoses of right rotator cuff tear and right glenohumeral joint osteoarthritis. Therefore, element (1) is satisfied. As for in-service injury or disease, the Veteran's service treatment records reflect that the Veteran injured his right elbow while falling on a hand in October 1992. He had pain on adduction and abduction of the right shoulder. The assessment was right elbow strain and sprain. In November 1992, there was mild crepitus during internal and external rotations of the right shoulder. The assessment was healing right radial fracture. Given that right shoulder symptomatology was noted during treatment for the right elbow disability in 1992, Hickson element (2) is met. Turning to medical nexus, there is conflicting medical evidence. A February 2012 VA examiner opined that it is less likely than not that the right shoulder disability was caused by or the result of military service. The examiner noted that while the Veteran was treated in service for a right elbow injury, no treatment was rendered for a right shoulder injury. The examiner stated that it as likely as not that the right shoulder disability developed after military service during construction work. In a March 2014 statement, a private doctor who treated the Veteran noted that his right shoulder disability stems from injuries he sustained while in service. The orthopedist noted that the service treatment records document him having pain and discomfort in the right shoulder with crepitus with internal and external rotation of the right shoulder in November 1992. The clinician noted that the Veteran has had intermittent problems with pain, catching, and weakness of the right shoulder since that original injury and that this symptomatology progressed to the point where he underwent surgery for a rotator cuff tear of the right shoulder with impingement and bone spurs. The doctor indicated that the most common mechanism for someone the Veteran's age stem from repeated traumas or overuse of the extremity where bone spurs and arthritic changes will develop that then cause chronic impairment in the shoulder area, which in turn impinges the rotator cuff. The orthopedist stated it is certainly within a reasonable degree of medical probability that the Veteran's current shoulder problems are at least related to his original shoulder injury and activities that he performed while in service and more specifically related to the direct injury that is well documented in 1992. VA treatment records reflect that in January 2016 a doctor noted that he or she cannot state the shoulder pain is the result of military service. In a February 2016 statement, a VA physician assistant indicated that a review of the Veteran's military records shows that he complained of right shoulder pain dating back to at least June 1988. The clinician noted that in October 1992 the Veteran fell on an overstretched right hand and sustained a right radial head fracture. The physician assistant stated that the mechanism of injury to the right elbow (fall on an overstretched arm and hand) is certainly a risk factor to injure and tear the rotator cuff in his right shoulder. The clinician noted a March 2011 operation note showing that the Veteran had a long history of recurrent pain in his right shoulder with a significant exacerbation in 1992 when he fell on the right elbow, resulting in a fracture. The physician assistant opined that based on the information available it is more likely than not that the Veteran's right elbow injury precipitated his right shoulder pathology, which ultimately led to a rotator cuff repair. In a June 2017 VA medical opinion, a June 2017 VA examiner opined that it is less likely than not that the Veteran's right shoulder disability is related to his active service. The doctor noted that while the Veteran was treated for both shoulders, there was no indication of a chronic right shoulder disability and that the separation examination was silent for shoulder complaints. The examiner noted that the Veteran checked yes for the box for painful or trick shoulder or elbow but that the description only mentioned a fracture of the right elbow. The Board notes that the February 2012 VA examiner did not address the documented in-service right shoulder symptomology in October and November 1992. The Board gives great weight to the March 2014 statement of the private physician because the doctor addressed the in-service right shoulder symptomatology and provided a thorough basis for his opinion. Similarly, the Board places considerable weight on the February 2016 statement of the VA physician assistant because it contains a thorough basis for the opinion. The Board notes that the June 2017 VA examiner provided a basis for his opinion but did not address the specific findings regarding the right shoulder in the October and November 1992 service treatment records. In light of the above, the evidence is in equipoise as to whether the right shoulder disability, to include arthritis with bone spurs, is related to the in-service right arm injury. Hence, element (3), medical nexus, is satisfied. In summary, the Board is of the opinion that the Veteran has met all requirements needed to establish service connection for a right shoulder disability, to include arthritis with bone spurs. The benefits sought on appeal are accordingly allowed. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. Entitlement to service connection for left shoulder arthritis with spurring Analysis In the July 2010 decision, the Board granted service connection for a left shoulder disability. In a July 2010 rating decision, a RO granted service connection for rotator cuff tear of the shoulder. The Board notes that service connection has not been granted for arthritis or bone spurs of the left shoulder. As for Hickson element (1), current disability, in a February 2008 statement, a private doctor stated that the Veteran's history, symptoms, examination, and diagnostic studies showed that he had some spurs that formed on the bones above the left shoulder joint and that the spurs pinched the rotator cuff muscles so much that the cuff had torn from the bone around the upper edge of the ball part of the shoulder joint. A March 2008 VA examination report reveals that the examiner determined that the Veteran did not have inflammatory arthritis of the left shoulder. A June 2017 VA examination report shows a diagnosis of glenohumeral joint osteoarthritis of the left shoulder. Therefore, element (1) is satisfied. Regarding Hickson element (2), in-service injury or disease, the Veteran's service treatment records contain an August 1986 report of medical history showing that the Veteran was taking Motrin for left shoulder pain. In March 1992 he was treated for left deltoid strain. Thus, element (2) is met. There is conflicting medical evidence on whether the arthritis with bone spurs is related to active service. A March 2008 VA examination report reflects that the examiner opined that the left shoulder injury is not a progression of the left shoulder complaint in service. In an April 2008 statement, the private doctor who performed the left shoulder surgery opined that in reviewing the Veteran's medical history, the surgery and rotator cuff pathology is service connected. The surgeon noted that the Veteran has a strong history of rotator cuff injuries and shoulder injuries in service that were treated conservatively. The clinician indicated that at the time of surgery, it was well documented that his cuff pathology was chronic and not a new injury. The doctor stated that within a reasonable degree of medical probability he would classify the shoulder pathology as service connected. In the March 2014 statement, the same private doctor noted that that the most common mechanism for a rotator cuff tear for someone the Veteran's age stem from repeated traumas or overuse of the extremity where bone spurs and arthritic changes will develop that then cause chronic impairment in the shoulder area, which in turn impinges the rotator cuff. In the June 2017 VA medical opinion, the June 2017 VA examiner opined that it is less likely than not that the Veteran's left shoulder disability is related to his active service. The doctor noted that while the Veteran was treated for both shoulders, there was no indication of a chronic left shoulder disability and that the separation examination was silent for shoulder complaints. The examiner noted that the Veteran checked yes for the box for painful or trick shoulder or elbow but that the description only mentioned a fracture of the right elbow. The private doctor stated that the bone spur in the right shoulder preceded the rotator cuff tear and indicated that arthritis can develop in the area of a rotator cuff tear. As noted above, service connection is in effect for rotator cuff tear of the left shoulder on a direct basis. In light of the above, the evidence is in equipoise as to whether the left shoulder arthritis with bone spurs is related to the in-service left shoulder injury. Hence, element (3), medical nexus, is satisfied. In summary, the Board is of the opinion that the Veteran has met all requirements needed to establish service connection for left shoulder arthritis with bone spurs. The benefits sought on appeal are accordingly allowed. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. Entitlement to service connection for right knee arthritis with bone spurs as secondary to service-connected status post strain of the right knee Governing law and regulations A disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary disorder, the secondary disorder shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). To establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Analysis Turning first to current disability, there is conflicting medical evidence on whether the Veteran has right knee arthritis with bone spurs. January 2005 VA X-rays of the right knee were normal. September 2005 VA X-rays of the right knee show minimal osteoarthritis. A July 2010 VA examination report reflects that the examiner stated there was no degenerative joint disease according to January 2005 X-rays. A June 2017 VA knee examination report shows a diagnosis of right knee joint osteoarthritis. The examiner noted that September 2005 X-rays revealed minimal osteoarthritis. A March 2018 VA examination report reveals that the examiner indicted that degenerative or traumatic arthritis of the right knee was noted. The examiner also noted that May 2017 X-rays of the right knee were normal. Given that one set of X-rays shows minimal osteoarthritis and two VA examiners diagnosed arthritis, the evidence is in equipoise as to whether the Veteran has arthritis of the right knee. Accordingly, Wallin element (1), current disability, is met. The Board notes that service connection has been granted for status post strain of the right knee. Thus, Wallin element (2), service-connected disability, is shown. The June 2017 VA examiner stated that the right knee osteoarthritis represents a progression of his service-connected right knee strain. The doctor stated that there is no separate diagnosis of bone spurs and that spurs are a sign of arthritis. The weight of evidence shows that the right knee arthritis with bone spurs was caused by the service-connected status post strain of the right knee. Therefore, service connection for right knee arthritis with bone spurs by means of causation is in order. 38 U.S.C. §§ 1110, 1131, 5107. 4. Entitlement to service connection for right elbow arthritis with spurs as secondary to residuals of a right radial head fracture December 2005 private X-rays of the right elbow revealed a minimal olecranon spur. A February 2012 VA examination report reflects a diagnosis of degenerative joint disease of the right elbow. A June 2017 VA elbow examination report shows a diagnosis of degenerative joint disease with residual bone spurs. Service connection has been granted for residuals of right radial head fracture Thus, Wallin element (2), service-connected disability, is shown. In a February 2016 statement, a VA physician assistant opined that the right radial head fracture developed into degenerative joint disease of the right elbow. The June 2017 VA examiner diagnosed right radial head fracture with degenerative joint disease of the right elbow and residual bone spurs. In a June 2017 medical opinion, that examiner noted that the right elbow spur is associated with the diagnosed arthritis and does not represent a separate diagnosis. The examiner added that arthritis is associated with the history of right radial head fracture in service. The weight of evidence shows that the right elbow arthritis with bone spurs was caused by the service-connected residuals of right radial head fracture. Therefore, service connection for right elbow arthritis with bone spurs by means of causation is in order. 38 U.S.C. §§ 1110, 1131, 5107. TDIU 5. Entitlement to TDIU based on PTSD with anxiety disorder not otherwise specified alone from June 15, 2017, to April 9, 2018 6. Entitlement to TDIU based on all service-connected disabilities from December 27, 2006, to June 14, 2017 Governing law and regulations Total disability ratings for compensation based on individual unemployability 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 without regard to advancing age 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 C.F.R. §§ 3.340, 3.341, 4.16(a). For the above purpose, disabilities affecting a single body system for example, orthopedic or neuropsychiatric are considered one disability. 38 C.F.R. § 4.16(a). For a veteran to prevail on a claim for a total compensation rating based on individual unemployability, the record must reflect some factor, which takes this case outside the norm. The simple fact that a claimant is currently unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993) (A high rating is recognition that the impairment makes it difficult to obtain or keep employment.). Age cannot be considered as a factor in evaluating a service-connected disability. Unemployability associated with advancing age or intercurrent disability cannot be used as a basis for a total disability rating. 38 C.F.R. § 4.19. In Bradley v. Peake, 22 Vet. App. 280 (2008), the Court held that, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of TDIU predicated on a single disability may form the basis for an award of special monthly compensation based on housebound status. Analysis From June 15, 2017, to April 9, 2018, the Veteran was service connected for PTSD with anxiety disorder not otherwise specified. From June 15, 2017, to April 9, 2018, PTSD with anxiety disorder not otherwise specified was rated 70 percent disabling. The 70 percent rating for the psychiatric disorder from June 15, 2017, to April 9, 2018, makes him eligible for consideration under 38 C.F.R. § 4.16(a) from June 15, 2017, to April 9, 2018, based on the psychiatric disorder alone. The Board will consider whether TDIU is warranted from June 15, 2017, to April 9, 2018, based on PTSD alone for purposes of entitlement to special monthly compensation based on housebound status. From April 30, 2009, to June 14, 2017, the Veteran was service connected for PTSD with anxiety disorder not otherwise specified, allergic rhinitis, a left shoulder disability, hypertension, bilateral knee disabilities, a right elbow disability, hearing loss, tinnitus, eczema, and left thigh scars. From April 30, 2009, to June 14, 2017, these service-connected disabilities were rated 90 percent disabling with PTSD with anxiety disorder not otherwise specified being rated as 50 percent disabling. This makes him eligible for consideration under 38 C.F.R. § 4.16(a) from April 30, 2009, to June 14, 2017. From December 27, 2006, to April 29, 2009, the Veteran was service connected for allergic rhinitis, a left shoulder disability, hypertension, bilateral knee disabilities, a right elbow disability, hearing loss, tinnitus, and eczema. From December 27, 2006, to April 29, 2009, these service-connected disabilities were rated 70 percent disabling with the orthopedic disabilities being rated 50 percent disabling. This makes him eligible for consideration under 38 C.F.R. § 4.16(a) from December 27, 2006, to April 29, 2009. In a February 2004 formal TDIU claim, the Veteran reported that painful joints the knees, shoulders, and right elbow prevents him from securing or following any substantially gainful occupation. He stated that his disability affected full-time employment in 2002 and 2003. He indicated that he last worked full time in May 2003, when he became too disabled to work. He reported he worked in construction and carpentry from 1995 to 2003. He stated that he had one year of college studying construction trades and that he had not had any education and training since he became too disabled to work. In a May 2004 statement, the Veteran's former employer reported that the Veteran worked full time from October 1997 to May 2003 in carpentry. The employer indicated that the Veteran resigned in May 2003 and that no concessions were made to him by reason of age or disability. The December 2005 VA examination report reveals that the examiner noted that the Veteran was unable to do lifting and squatting at his construction job and that he quit his job in 2003. The doctor stated that the major impact on the Veteran's unemployability is from his knees and right elbow. The clinician added that the Veteran is unfit for physical employment due to the knees and right shoulder. The Veteran stated that he has no office skills and that he is unable to sit still for more than 20 minutes because he needs to stretch his knees from time to time. The examiner stated that the Veteran is unfit for sedentary employment because he needs to stretch his knees for a few minutes when he sits for more than 20 minutes. A June 2007 private treatment record shows that the Veteran's hearing impairment is a reduced ability to understand conversations, especially in the presence of noise. In an April 2008 statement, a former coworker reported the Veteran had trouble with his knees and shoulders and would take pain medications daily. The colleague stated that the Veteran was absent from work due to swelling of the knees and shoulder pain. The coworker added that the Veteran could not stand for long periods of time, walk on unlevel ground, run a bobcat, or work with trusses without having to sit down due to pain. The colleague stated that he eventually had to quit his job and stay at home due to his physical conditions. In a June 2008 statement, the Veteran's former superintendent said that the Veteran had severe problems with his knees and rotator cuff injuries that limited his work activities. The colleague stated that the Veteran took pain medication every day to allow him to do his job but that sometimes he took time off from work. The coworker noted that after six years the Veteran finally quit working. Private treatment records reflect that a psychiatrist noted in April 2009 the Veteran had PTSD with concentration impairment, sleep disturbance, severe interpersonal relationship problems, and severe job impact. The doctor noted that the PTSD symptoms were all having a severe impact on his ability to maintain employment. In June 2009, the clinician noted the same symptoms. In August and October 2009, the psychiatrist noted that the Veteran had PTSD with concentration impairment, sleep pattern disturbance, interpersonal relationship problems, and unemployability. A July 2010 VA PTSD examination report reveals that the examiner noted that the Veteran stopped working mainly because of physical problems with his knees, back, and shoulders. The Veteran noted that he would like to work. The examiner stated that other than the fact that the Veteran does not sometimes sleep well, he does not appear to have more than mild-to-moderate impairment in occupational reliability and productivity as a result of his psychological issues. A July 2010 VA audiological examination report reflects that the Veteran has difficulty hearing noise or hearing in crowds. A November 2010 VA examination report shows that the examiner determined that the allergic rhinitis causes no effect on the Veteran's usual occupation. A November 2010 VA joint examination report reflects that the Veteran reported he quit working in construction because of increased pain in his joints. The examiner stated that the right shoulder and right elbow disabilities had significant effects on his usual occupation because of problems with lifting and carrying as well as pain. The examiner noted that the resulting work problem was that he was assigned different duties. Records from the Social Security Administration reveal that the agency denied the Veteran's claim for disability benefits in June 2011. The primary disability was dysfunction of major joints, and the secondary disability was essential hypertension. The other disabilities were other and unspecified arthropathies and hearing loss. All of these disabilities were considered severe. The Veteran had exertional limitations, such as sitting for about six hours in a normal eight-hour workday with normal breaks. The agency found that the Veteran had some limitations in the performance of certain work activities but that these limitations would not prevent the Veteran from performing past relevant work as a laborer. The agency concluded that the Veteran was not disabled. In a January 2013 formal TDIU claim, the Veteran reported that degenerative joint disease prevents him from securing or following any substantially gainful occupation. He stated that he had two years of college and that he had not had any education and training since he became too disabled to work. A June 2015 VA rhinitis examination report shows that the examiner determined that the allergic rhinitis impacts the Veteran's ability to work. The examiner noted that the allergic rhinitis would be aggravating in a work setting but that it would not affect any particular activity. A June 2015 VA elbow examination report reflects that the right elbow disability impacts any occupational activity requiring use of the right arm and hand. A November 2015 VA audiological examination report reveals that the Veteran has hearing difficulty that impacts his ability to work but that his tinnitus does not impact his ability to work. A June 2017 VA PTSD examination report reflects that the examiner determined that the Veteran had an occupational and social impairment with reduced reliability and productivity. The Veteran had obsessional rituals that interfere with routine activities, an inability to establish and maintain effective relationships, and difficulty in adapting to stressful circumstances, including work or work-like setting. A June 2017 VA skin diseases examination report shows that the examiner determined that the skin disease does not impact the Veteran's ability to work. The June 2017 VA shoulder examination report reveals that the examiner determined that the bilateral shoulder disabilities impact the Veteran's ability to perform occupational tasks because he will have difficulty with strenuous activity. The June 2017 VA knee examination report shows that the examiner determined that the bilateral knee disabilities impact the Veteran's ability to perform occupational tasks because he will have difficulty with bending, squatting, climbing ladders, negotiating steps frequently, and sitting, standing, or walking for long periods of time. The June 2017 VA elbow examination report shows that the examiner determined that the right elbow disability impacts the Veteran's ability to perform occupational tasks because he will have difficulty with strenuous activity and difficulty using a computer mouse with the right hand. In a June 2017 medical opinion, the June 2017 VA examiner addressed the Veteran's functional limitations. The examiner noted that impact of hearing loss and tinnitus and the impact of anxiety should be evaluated by an audiologist and mental health professional, respectively. The doctor noted that the allergic rhinitis, hypertension, and left thigh scars would have no significant impact on physical or sedentary work activities. The June 2017 VA examiner stated that the left shoulder disability would likely preclude the Veteran from performing moderate-to-heavy physical labor but that this disability should have no significant impact on sedentary work or light duty. The examiner added that the Veteran would likely have difficulty with jobs requiring lifting over 20 pounds frequently but that he is able to perform overhead work. The doctor indicated that the bilateral knee disability likely precludes the Veteran from work requiring frequent lifting or carrying over 30 pounds, squatting, or kneeling, but that he would likely be able to tolerate light physical duty and sedentary work. The clinician added that due to pain with prolonged sitting, the Veteran would likely require either an ergonomic workstation in which he could work sitting or standing or taking five-minute breaks to stand and stretch his legs. The examiner stated that the right elbow disability would likely limit jobs requiring frequent use of manual tools, such as a screwdriver or wrench. The doctor noted that the Veteran complained of difficulty operating a mouse but that he is able to compensate by operating the mouse with his left hand. The June 2018 VA knee examination report shows that the examiner determined that the bilateral knee disabilities impact the Veteran's ability to perform occupational tasks because he states he cannot bear weight for prolonged periods of time due to bilateral knee pain. The June 2018 VA elbow examination report shows that the examiner determined that the right elbow disability impacts the Veteran's ability to perform occupational tasks. The examiner noted that the Veteran worked in construction for six years as a project supervisor at worksites. The Veteran reported that climbing ladders was hard on his right elbow. The examiner noted that the Veteran left work primarily due to his left knee disability but that he had elbow pain too. For the period from June 15, 2017, to April 9, 2018, the Board places considerable weight on the findings from the June 15, 2017, VA PTSD examination report showing that the Veteran had obsessional rituals that interfere with routine activities, an inability to establish and maintain effective relationships, and difficulty in adapting to stressful circumstances, including work or work-like setting. From June 15, 2017, to April 9, 2018, the evidence is in equipoise as to whether Veteran's service-connected PTSD with anxiety disorder not otherwise specified alone rendered him unemployable from performing all forms of substantially gainful employment that are consistent with his education and occupational experience. Accordingly, entitlement to TDIU based on the PTSD with anxiety disorder not otherwise specified alone from June 15, 2017, to April 9, 2018, in order. For the period from April 30, 2009, to June 14, 2017, the Board places considerable weight on the private psychiatric treatment records showing employment impairment. The Board notes the July 2010 VA examiner's finding that there is no more than mild-to-moderate impairment in occupational reliability and productivity as a result of his psychological issues but only when the Veteran does not have sleep impairment. The June 2017 VA examination report reflects that the Veteran has had chronic sleep impairment. Private treatment records from 2009 reveal that PTSD was manifested by sleep pattern disturbance. The Board places great weight on the findings of sleep impairment. The Board places substantial weight on the functional impairments from the orthopedic disabilities noted by the June 2017 VA examiner and in the VA examination reports from November 2010 to June 2017. The Board notes that the June VA examiner stated that due to pain with prolonged sitting, the Veteran would likely require either an ergonomic workstation in which he could work sitting or standing or taking five-minute breaks to stand and stretch his legs. Although the December 2005 VA examination report predates the period from April 30, 2009, to June 14, 2017, the Board gives great weight to that examination report because it notes the Veteran's need to take a few-minute breaks every 20 minutes because of knee pain from sitting. Although the Social Security Administration denied disability benefits in June 2011, the Board notes that the agency did not consider the Veteran's psychiatric disorder in its determination. The Board also notes that the functional impairments from the orthopedic disabilities are more thoroughly described in the VA examination reports than in the decision and determinations by the Social Security Administration. The Board also places much weight on the findings from the July 2010 VA audiological examination regarding hearing impairment. In light of the above, from April 30, 2009, to June 14, 2017, the evidence is in equipoise as to whether Veteran's service-connected disabilities rendered him unemployable from performing all forms of substantially gainful employment that are consistent with his education and occupational experience. Accordingly, entitlement to TDIU based on all service-connected disabilities from April 30, 2009, to June 14, 2017, in order. As for the period from December 27, 2006, to April 29, 2009, the Board again places great weight on the findings from the December 2005 VA examination report regarding impairment from the right elbow and bilateral knee disabilities. The Board also places great weight on the finding of functional impact from the hearing loss as noted in the June 2007 private treatment record. From December 27, 2006, to April 29, 2009, the evidence is in equipoise as to whether Veteran's service-connected disabilities rendered him unemployable from performing all forms of substantially gainful employment that are consistent with his education and occupational experience. As such, entitlement to TDIU based on all service-connected disabilities from December 27, 2006, to April 29, 2009, in order. Special Monthly Compensation 7. Entitlement to special monthly compensation since June 15, 2017 Governing law and regulations 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i), which provides for special monthly compensation at the housebound rate where a veteran has a single service-connected disability rated as 100 percent disabling and has additional service-connected disability or disabilities independently rated at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. Analysis Since April 10, 2018, the service-connected disabilities other than PTSD have been rated as 100 percent disabling and the service-connected PTSD with anxiety disorder not otherwise specified has been independently rated as 70 percent disabling. TDIU based on PTSD with anxiety disorder not otherwise specified alone has now been granted from June 15, 2017, to April 9, 2018. From June 15, 2017, to April 9, 2018, the service-connected disabilities other than PTSD with anxiety disorder not otherwise specified have been independently rated as 70 percent disabling. Accordingly, special monthly compensation at the housebound rate under 38 U.S.C. § 1114; 38 C.F.R. § 3.350(i) is warranted since June 15, 2017. REASONS FOR REMAND In the May 2018 remand, the Board noted that a supplemental statement of the case was issued but that it did not include the issues of service connection for a right hip disability, a left hip disability, bone spurs, and a joint disability, to include arthritis. The Board directed the RO to readjudicate all remanded issues and that if any benefit on appeal is denied, the Veteran and his representative must be provided a supplemental statement of the case and be given an opportunity to respond. In March 2020, the RO issued a supplemental statement of the case that addressed entitlement to service connection for a right hip disability and a left hip disability. That supplemental statement of the case did not address any other pending service connection regarding bone spurs and arthritis. Therefore, the RO did not comply with the directives of the May 2018 Board remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). Pursuant to the February 2017 remand, the Veteran underwent VA elbow/forearm and knee examinations in June 2017. Regarding whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or with flare-ups, the examiner stated that it was not possible to answer without resorting to mere speculation because there was no conceptual or empirical basis for making such a determination without directly observing function under these conditions. In the May 2018 remand, the Board noted that in Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that examiners must offer opinions with respect to the additional limitation of motion during flare-ups based on estimates derived from information procured from relevant sources, including a veteran's lay statements. The Court explained that an examiner must do all that reasonably could be done in order to become informed before concluding that a requested opinion cannot be provided without resorting to speculation. In accordance with Sharp, the Board ordered new examinations. The August and September 2018 VA examination reports reflect that the VA examiners did not render opinions on with respect to additional limitations during flare-ups and repeated use over time because the Veteran was not examined during a flare-up or during repeated use over time. The RO again did not comply with the directives of the May 2018 Board remand. Stegall, 11 Vet. App. at 271. The Veteran's service treatment records reflect that he was treated for subjective back pain in February 1992. A VA examination is necessary to determine whether any arthritis of the back is related to service or secondary to a service-connected disability. A VA examination is necessary to determine whether the Veteran has a disability manifested by bone spurs in the left elbow and whether such a disability is related to service or secondary to a service-connected disability. In a March 2009 statement, a fellow veteran reported that he was a primary non-physician medical practitioner in service and that he treated the Veteran for joint pain of the hips and hands. At a June 2017 VA hand examination, the Veteran reported that he had had chronic pain in the right hand since the late 1970s. He, however, denied having any pain in the left hand. At a June 2017 VA hip examination, the Veteran reported a history of bilateral hip since the late 1980s. At a November 2009 hearing, the Veteran testified that he first noticed hip pain in the mid-1970s. November 2009 hearing transcript, page 32. The Veteran is competent to report his history of right hand and bilateral hip pain, and the Board finds him credible, especially since he reported a history of swollen or painful joints at his separation examination. In the June 2017 medical opinion, the June 2017 VA examiner rendered a negative medical nexus opinion on the bilateral arthritis of the hands. The examiner, however, did not address the Veteran's continuity of symptomology regarding right hand pain or the March 2009 statement from a fellow veteran regarding in-service joint pain. A new VA examination is necessary to address that matter as well as whether the bilateral arthritis of the hands is secondary to service-connected disabilities. In the June 2017 medical opinion, the June 2017 VA examiner rendered a negative medical nexus opinion on the bilateral hip disability on the basis that the service treatment records are silent for bilateral hip complaints. The examiner, however, did not address the Veteran's continuity of symptomology regarding bilateral hip pain, the March 2009 statement from a fellow veteran regarding in-service joint pain, or an August 1986 report of medical history showing that the Veteran was taking Motrin for left hip pain. A new VA examination is necessary to address that matter as well as whether the bilateral hip disabilities are secondary to service-connected disabilities. In a December 2005 statement, the Veteran reported being treated at the Salisbury VA Medical Center from February 1994 to May 1994. In an October 2005 statement, the Veteran reported that he had been primarily treated by VA since he retired from military service. At the January 2016 hearing, he testified that he had been treated by the Salisbury VA Medical Center and Winston-Salem VA outpatient clinic since within a year and half of leaving active service. The RO obtained records from those facilities from September 1998 to March 2020. In a July 2005 statement, the Veteran reported that he was receiving treatment from Dr. Viberal. A February 2012 VA examination report reveals that the Veteran underwent right shoulder surgery at Elkin Hospital in 2009. A review of the records shows that the Veteran has been treated by Dr. Whitman of Tri County Orthopedics and at Hugh Chatham Memorial Hospital and Northern Hospital of Surry County. In the analysis granting TDIU for the period from December 27, 2006, to June 14, 2017, the Board discussed the medical evidence regarding functional impairment from the orthopedic disabilities and the psychiatric disorder. In Snider v. McDonough, 35 Vet. App. 1 (2021), the Court found that pursuant to Ray v. Wilkie, 31 Vet. App. 58, 66 (2019), entitlement to an extraschedular TDIU must be referred to the Director of Compensation Service for an initial determination where there is sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable due to service-connected disabilities. The Court found that when denying an extraschedular TDIU referral to the Director under § 4.16(b), the Board must make two determinations in its decision: (1) that a referral for extraschedular TDIU is not warranted under the "reasonable possibility" standard set forth in Ray, and (2) that TDIU benefits are not warranted because the veteran is not unemployable due to service-connected disabilities. Considering the findings discussed above regarding the psychiatric disorder, the claim for TDIU based on the psychiatric disorder alone for the period from April 30, 2009, to June 14, 2017, for purpose of special monthly compensation based on housebound status should be referred to the Director for extraschedular consideration. Considering the findings discussed above regarding the orthopedic disabilities, the claim for TDIU based on the orthopedic disabilities alone for the period from April 30, 2009, to June 14, 2017, for the purpose of special monthly compensation based on housebound status should be referred to the Director for extraschedular consideration for any period in which the Veteran does not meet the criteria for consideration of TDIU under 38 C.F.R. § 4.16(a) for the orthopedic disabilities alone. Considering the findings discussed above regarding the orthopedic disabilities, the claim for TDIU prior to December 27, 2006, should be referred to the Director for extraschedular consideration for any period in which the Veteran does not meet the criteria for consideration of TDIU under 38 C.F.R. § 4.16(a) for the period from June 3, 2003, to December 26, 2006. The issue of entitlement to special monthly compensation based on housebound status prior to June 15, 2017, is inextricably intertwined with the remaining TDIU issues. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are "inextricably intertwine" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). The matters are REMANDED for the following action: 1. Ask the Veteran to identify all treatment for his bilateral elbow disabilities, bilateral knee disabilities, bilateral hip disabilities, bilateral shoulder disabilities, bilateral hand and fingers disabilities, and the psychiatric disorder as well as any other disabilities pertaining to the claim for TDIU. Obtain any identified records. Obtain the Veteran's VA treatment records from the Salisbury VA Medical Center and the Winston-Salem and Kernersville VA outpatient clinics from May 1994 to September 1998 and from March 2020 to the present. Ask the Veteran to complete a VA Form 21-4142 for Drs. Viberal and Whitman and Hugh Chatham Memorial Hospital, Northern Hospital of Surry County, and Elkin Hospital. Make two requests for the authorized records from Drs. Viberal and Whitman and Hugh Chatham Memorial Hospital, Northern Hospital of Surry County, and Elkin Hospital, unless it is clear after the first request that a second request would be futile. 2. After the development in 1 is completed, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral knee disabilities and right elbow disabilities and the natures and etiologies of the bilateral hip disabilities, bone spurs of the left elbow, arthritis with bone spurs of the hands, and arthritis of the spine. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing, in both knees and elbows. The examiner should provide specific measurements for active and passive motions. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). In so doing, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training) For any arthritis of the spine, the examiner must opine for whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability is related to an in-service injury, event, or disease, to include treatment for subjective back pain in February 1992. The examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any arthritis of the back (1) began during active duty, or (2) manifested within one year after discharge from service in May 1994. For any arthritis of the spine, the examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability was (1) caused by or (2) aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars. If the examiner finds that arthritis of the back was aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars then the medical professional should quantify the degree of aggravation. For any disability manifested by bone spurs of the left elbow, the examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability is related to an in-service injury, event, or disease. If the disability manifested by bone spurs of the left elbow is diagnosed as arthritis, the examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any arthritis of the left elbow (1) began during active duty, or (2) manifested within one year after discharge from service in May 1994. For any disability manifested by bone spurs of the left elbow, the examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability was (1) caused by or (2) aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars. If the examiner finds that disability manifested by bone spurs of the left elbow was aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars then the medical professional should quantify the degree of aggravation. The examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the arthritis in the left hand is related to an in-service injury, event, or disease, to include the left hand injury in October 1992 and the treatment of hand pain as reported by a fellow veteran in a March 2009 statement. The examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the arthritis of the left hand (1) began during active duty, or (2) manifested within one year after discharge from service in May 1994. The examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the arthritis of the left hand was (1) caused by or (2) aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars. If the examiner finds that the arthritis of the left hand was aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars then the medical professional should quantify the degree of aggravation. The examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the arthritis in the right hand is related to an in-service injury, event, or disease, to include the right hand injuries in June 1976 and October 1992 and the treatment of hand pain as reported by a fellow veteran in a March 2009 statement. Accepting the Veteran's reporting of continuity of right hand pain symptomatology since service as credible, the clinician must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the arthritis of the right hand (1) began during active duty, (2) was manifested within one year after discharge from his period of active service in May 1994, or (3) was noted during service with continuity of the same symptomatology of right hand pain since service. The examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the arthritis of the right hand was (1) caused by or (2) aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars. If the examiner finds that the arthritis of the right hand was aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars then the medical professional should quantify the degree of aggravation. For arthritis of the left hip, left hip strain, trochanteric pain syndrome of the left hip, and any other current left hip disability, the examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that left hip disability is related to an in-service injury, event, or disease, to include taking Motrin for left hip pain as reported in an August 1986 report of medical history and the treatment of hip pain as reported by a fellow veteran in a March 2009 statement. Accepting the Veteran's reporting of continuity of left hip pain symptomatology since service as credible, the clinician must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the arthritis of the left hip (1) began during active duty, (2) was manifested within one year after discharge from his period of active service in May 1994, or (3) was noted during service with continuity of the same symptomatology of left hip pain since service. The examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that arthritis of the left hip, left hip strain, trochanteric pain syndrome of the left hip, and any other current left hip disability were (1) caused by or (2) aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars. If the examiner finds that arthritis of the left hip, left hip strain, trochanteric pain syndrome of the left hip, or any other current left hip disability was aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars then the medical professional should quantify the degree of aggravation. For arthritis of the right hip, right hip strain, trochanteric pain syndrome of the right hip, and any other current right hip disability, the examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that left hip disability is related to an in-service injury, event, or disease, to include the treatment of hip pain as reported by a fellow veteran in a March 2009 statement. Accepting the Veteran's reporting of continuity of right hip pain symptomatology since service as credible, the clinician must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the arthritis of the right hip (1) began during active duty, (2) was manifested within one year after discharge from his period of active service in May 1994, or (3) was noted during service with continuity of the same symptomatology of right hip pain since service. The examiner must opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that arthritis of the right hip, right hip strain, trochanteric pain syndrome of the right hip, and any other current right hip disability were (1) caused by or (2) aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars. If the examiner finds that arthritis of the right hip, right hip strain, trochanteric pain syndrome of the right hip, or any other current right hip disability was aggravated by the service-connected PTSD with anxiety disorder not otherwise specified, type II diabetes mellitus with erectile dysfunction, diabetic peripheral neuropathy of all four extremities, allergic rhinitis, the bilateral shoulder disabilities, the right elbow disability, the bilateral knee disabilities, hypertension, hearing loss, tinnitus, eczema, or left thigh scars then the medical professional should quantify the degree of aggravation. 3. After the development in 1 and 2 is completed, the RO should undertake any necessary development on the claim for service connection for bone spurs of the left knee as warranted by any additional evidence of record. 4. After the development in 1 is completed, RO should refer the claim of entitlement to TDIU based on PTSD with anxiety disorder not otherwise specified alone from April 30, 2009, to June 14, 2017, for the purpose of special monthly compensation based on housebound status to the Director of Compensation Service for consideration of the assignment of an extraschedular rating for the period from April 30, 2009, to June 14, 2017. 5. After the development in 1 and 2 is completed and after effective dates and ratings are assigned for the right shoulder disability, arthritis with bone spurs of the left shoulder, arthritis with bone spurs of the right elbow, and arthritis with bone spurs of the right knee, the RO should refer the claim of entitlement to TDIU for the orthopedic disabilities alone from April 30, 2009, to June 14, 2017, for the purpose of special monthly compensation based on housebound status to the Director of Compensation Service for consideration of the assignment of an extraschedular rating for any period from April 30, 2009, to June 14, 2017, in which the Veteran does not meet the criteria for consideration of TDIU under 38 C.F.R. § 4.16(a) (2022) for the orthopedic disabilities alone. 6. After the development in 1 and 2 is completed and after effective dates and ratings are assigned for the right shoulder disability, arthritis with bone spurs of the left shoulder, arthritis with bone spurs of the right elbow, and arthritis with bone spurs of the right knee, the RO should refer the claim of entitlement to TDIU prior to December 26, 2006, to the Director of Compensation Service for consideration of the assignment of an extraschedular rating for any period from June 3, 2003, to December 25, 2006 in which the Veteran does not meet the criteria for consideration of TDIU under 38 C.F.R. § 4.16(a) (2022). 7. Thereafter, readjudicate the claims on appeal. If any benefit sought in connection with the claims remain denied, the Veteran and his representative should be provided with an appropriate Supplemental Statement of the Case (SSOC) and given the opportunity to respond. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Cherry, David T. 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.