Citation Nr: 23048874 Decision Date: 09/06/23 Archive Date: 09/06/23 DOCKET NO. 19-24 377 DATE: September 6, 2023 ORDER 1. Service connection right foot cold weather injury is denied. 2. Service connection left foot cold weather injury is denied. 3. Service connection right hand cold weather injury is denied. 4. Service connection left hand cold weather injury is denied. 5. Service connection for bilateral pes planus is denied. 6. Service connection for bilateral plantar fasciitis is denied. 7. Service connection for acquired psychiatric disorder, to include as secondary to service-connected disability/disabilities, is denied. 8. Service connection for a headache disorder, to include as secondary to service-connected disability/disabilities, is denied. 9. Service connection for low back disorder, to include as secondary to service- connected disability/disabilities, is denied. 10. Entitlement to a total disability rating based upon unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. The probative evidence persuasively shows that a right foot cold weather injury did not have its onset in service and persuasively shows that a right foot cold weather injury is not otherwise related to active-duty service. 2. The probative evidence persuasively shows that a left foot cold weather injury did not have its onset in service and persuasively shows that a left foot cold weather injury is not otherwise related to active-duty service. 3. The probative evidence persuasively shows that a right hand cold weather injury did not have its onset in service and persuasively shows that a right hand cold weather injury is not otherwise related to active-duty service. 4. The probative evidence persuasively shows that a left hand cold weather injury did not have its onset in service and persuasively shows that a left hand cold weather injury is not otherwise related to active-duty service. 5. The probative evidence persuasively shows that bilateral pes planus did not have its onset in service and persuasively shows that bilateral pes planus is not otherwise related to active-duty service. 6. The probative evidence persuasively shows that bilateral plantar fasciitis did not have its onset in service and persuasively shows that bilateral plantar fasciitis is not otherwise related to active-duty service. 7. The probative evidence persuasively shows that an acquired psychiatric disorder did not have its onset in service and is not otherwise related to active-duty service. The probative evidence persuasively shows that an acquired psychiatric disorder was not proximately caused by or aggravated beyond normal progression by any service-connected disability. 8. The probative evidence persuasively shows that a headache disorder did not have its onset in service and is not otherwise related to active-duty service. The probative evidence persuasively shows that a headache disorder was not proximately caused by or aggravated beyond normal progression by any service-connected disability. 9. The probative evidence persuasively shows that a low back disorder did not have its onset in service or within one year of separation from service and is not otherwise related to active-duty service. The probative evidence persuasively shows that a low back disorder was not proximately caused by or aggravated beyond normal progression by any service-connected disability. 10. The competent and probative evidence is not in relative equipoise as to whether the Veteran's service-connected tinnitus renders him unable to obtain and sustain substantially gainful employment. The competent and probative evidence is not in relative equipoise as to whether service-connected tinnitus presents a "reasonable possibility" that the Veteran is unable to obtain and sustain substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for right foot cold weather injury have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for left foot cold weather injury have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304 3. The criteria for service connection for right hand cold weather injury have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. The criteria for service connection for left hand cold weather injury have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 5. The criteria for service connection for bilateral pes planus have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 6. The criteria for service connection for bilateral plantar fasciitis have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 7. The criteria for service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 8. The criteria for service connection for a headache disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 9. The criteria for service connection for a low back disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 10. The criteria for entitlement to a TDIU, on an extraschedular basis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 4.3, 4.16, 4.18; Snider v. McDonough, 35 Vet. App. 1 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active-duty service in the United States Army from October 1976 to July 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal of a September 2017 rating decision of the Department of Veterans Affairs (VA). On both May 24, 2022, and May 26, 2022, the Veteran testified at Board hearings before the undersigned Veterans Law Judge. The Veterans claims file contains copies of the transcripts. In November 2022, the Board remanded these matters for additional evidentiary development. Upon review of the record, there has been substantial compliance with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order); Dyment v. West, Vet. App. 141, 147 (1999) (clarifying that substantial compliance with a Board remand is required). The analyses below focus on the most salient and the most relevant evidence about what this evidence shows, or fails to show, about the issues on appeal. The Veteran must not assume that the Board has overlooked pieces of evidence that are not discussed explicitly. Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Threshold Issue Upon review of the evidence of record, there have been multiple attempts to obtain all of the Veteran's service treatment records. A review of the record shows concerted efforts to obtain the totality of these records. In a June 2017, Memorandum of Record, the VA Records Management Center [RMC] opined that: The RMC has conducted multiple searches of our files activity for all records which may be associated with this Veteran, to include claims folder and Service Treatment Records. Unfortunately, no records were located for this Veteran at the RMC. To support your efforts, we have "FLAGGED" our filing system to indicate your interest in the event the hard copy record is located in the future. If the record is located, we will immediately forward the folder for scanning and, if no claim is pending, send email notification to the VSC mailbox and designated IPC contact(s)of the station who adjudicated the most recent claim. In this situation, the Board has a heightened obligation to explain its findings and conclusions and to carefully consider the benefit-of- the-doubt doctrine. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The O'Hare precedent does not lower the threshold for an allowance of a claim; there is no reverse presumption for granting a claim. The legal standard for proving a claim is not lowered; rather, the Board's obligation to discuss and evaluate evidence is heightened. Russo v. Brown, 9 Vet. App. 46 (1996). Case law does not establish a heightened "benefit of the doubt," only a heightened duty of the Board to consider the applicability of the benefit-of-the-doubt doctrine, to assist the claimant in developing the claim, and to explain its decision when a claimant's medical records have been lost or destroyed. Ussery v. Brown, 8 Vet. App. 64 (1995). Thus, missing documentation is indeed unfortunate, but any absence does not obviate the need for the Veteran to still have competent and credible evidence supporting his claim for service connection. Milostan v. Brown, 4 Vet. App. 250, 252 (1993) (citing Moore v. Derwinski, 1 Vet. App. 401 (1991) and O'Hare, 1 Vet. App. at 367). 1. Service connection right foot cold weather injury is denied. 2. Service connection left foot cold weather injury is denied. 3. Service connection right hand cold weather injury is denied. 4. Service connection left hand cold weather injury is denied. 5. Service connection for bilateral pes planus is denied. 6. Service connection for bilateral plantar fasciitis is denied. 7. Service connection for acquired psychiatric disorder, to include as secondary to service-connected disability/disabilities, is denied. 8. Service connection for a headaches disorder, to include as secondary to service-connected disability/disabilities, is denied. 9. Service connection for low back disorder, to include as secondary to service- connected disability/disabilities, is denied. In order to establish service connection on a direct basis, the record must contain competent evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). In the absence of proof of a present disability there can be no valid claim. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease, however remote, are service connected, unless clearly attributable to intercurrent causes. Entitlement to service connection based on chronicity pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). A disability which is proximately due to, or the result of, a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Here, the Board observes that aggravation, according to the Court, constitutes "any incremental increase in disability and any additional impairment of earning capacity in non-service-connected disabilities resulting from service-connected conditions regardless of its permanence." Ward v. Wilkie, 31 Vet. App. 233, 241-42 (2019). Consequently, "aggravation beyond natural progression" inquiries should not be limited to the definition of aggravation as a permanent worsening of the condition beyond its natural progression. Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Consequently, where there is evidence showing that a disorder manifested or was incurred in service, and this disorder is not noted on the Veteran's entrance examination report, this presumption of soundness operates to shield the Veteran from any finding that the unnoted disease or injury preexisted service. Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991); 38 C.F.R. § 3.304(b). The presumption is only rebutted where the evidence clearly and unmistakably shows that the veteran's disability (1) existed before acceptance and enrollment into service and (2) was not aggravated by service. Wagner v. Principi, 370 F. 3d 1089, 1096 (Fed. Cir. 2004); Bagby, 1 Vet. App. 227; VAOGCPREC 3-2003 (July 16, 2003); Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). To satisfy this second requirement for rebutting the presumption of soundness, the government must show by clear and unmistakable evidence that there was no increase in disability during service or that any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F. 3d 845, 847 (Fed. Cir. 2006). Relevant Evidence and Intercalated Analyses The Veteran's extant service treatment records includes a March 1975 ROTC report of medical examination. Here, the clinician reported that all of the Veteran's somatic systems and psychological status were normal. Through indicated with both slashes and "x's", the June 1975 ROTC report of medical examination replicates these normal evaluations. In the March 1975 report of medical history, the Veteran reported that he had not had and did not have swollen or painful joints, leg cramps, arthritis, recurrent back pain, lameness, finger or toe loss, foot trouble, or depressive/excessive worry. In his June 1975 report of medical history, the Veteran reported largely the same; however, he indicated that he had broken bones, foot trouble, and nervous trouble. VA records disclose that the Veteran received on-going impressions of both personality disorder not otherwise specified (NOS) and psychotic disorder NOS. The Veteran sought treatment at several VA facilities for a host of physical maladies, to include diabetes mellitus; skin disorders; foot problems; visual testing; and Raynaud's syndrome. Upon review of the Veteran's VA problems list from the Carl Vinson VAMC, as of 2017, the Veteran's ongoing problems list included, among other disabilities, personality disorder not otherwise specified (NOS); psychotic disorder NOS; adjustment disorder NOS; generalized anxiety disorder; acute sinusitis; dysthymia; paranoid personality; shoulder pain; hypertension; and congenital pes planus. In a July 2017 lay statement, the Veteran's military colleague reported that the Veteran's wife abandoned him while he was carrying out military duties. He also reported that the Veteran became a heavy smoker in service and now suffers from posttraumatic stress disorder (PTSD), chronic obstructive pulmonary disease (COPD), and heart disease. Since service, according to this lay informant, the Veteran has been unable to maintain gainful employment; has experienced financial problems; and has become mentally unstable. The colleague reported that he believed that all of the Veteran's disabilities were attributable to active-duty service. In August 2017, the Veteran reported for a VA PTSD examination. A VA psychologist reviewed the claims file; considered the Veteran's accounts of his psycho-medical history; and conducted an appropriate evaluation (hereinafter "VA exam protocols"). This psychologist rendered diagnoses of anxiety disorder NOS and personality disorder NOS. Based upon the totality of evidence, the psychologist rendered a negative etiological opinion. As a rationale to support this opinion, the psychologist opined that, There is no diagnosis of PTSD. Therefore, PTSD is not service related. The Veteran's current diagnosis of unspecified anxiety disorder meets DSM criteria, but there is no evidence that it is related to the Veteran's military service. There is no report of mental health issues during the Veteran's service time and no consistent report of ongoing mental health problems since military service. Therefore, there is no nexus between military service and currents symptoms. The claimant's medical record including notes related to anxiety, depression and sleep disturbance were reviewed. The notation related to anxiety, depression and sleep disturbance in the notes referred to items listed on his Report of Medical History during enlistment. The psychiatrist found no evidence of a psychological problem. He stated that the cadet had no anxiety, depression, sleep disturbance, or other symptom. Anxious and depressive ideation center on feeling that he was singled out while in the military. However, there is insufficient evidence to support this reported mistreatment as causative. Upon review of the Veteran's Dublin VAMC progress notes, the Veteran requested a consultation for Raynaud's syndrome in May 2019. In turn, a VA-certified family nurse practitioner (FNP-C) provided an assessment of such a disease entity in a July 2019 primary care note. At the time, this FNP-C opined that, [The] Veteran was seen in podiatry [and it] was noted that he had some discoloration of his feet and told [that] he could possibly need a vascular [consultation]. [The Veteran had] good pulse in his feet, warm to touch. While in [...] service the Veteran was exposed to cold temperatures and suffered frostbite and has developed Raynaud's [syndrome]. Upon physical examination, the FNP-C reported that the Veteran's maintained 2 plus pulses at the extremities and 1 plus pulses with edema at the bilateral ankles. Based upon the afore-noted intercalated podiatry report and these two findings upon physical examination, the FNP-C rendered her assessment of Raynaud's phenomenon, advising that the Veteran avoid cold exposure; maintain digital warmth; and cease smoking. As to the in-service "frostbite," the FNP-C provided no guidance. The Board recognizes that the FNP-C did not perform a VA examination, and-as such-was not tasked with rendering an etiological opinion. But, this primary care note, in both its brevity and its unsupported conclusion, quite simply, does not rise to the level of ensuring that the Board's "'evaluation of the Veteran's claimed quadrilateral extremity cold injuries will be a fully informed one.'" Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). As noted above, the Board remanded this issue for additional evidentiary development in November 2022. At the afore-noted 2022 Board hearings, the Veteran testified extensively as to the incurrence and on-going symptoms of his quadrilateral extremity cold injuries. The Veteran also conveyed that he had received a diagnosis of Raynaud's syndrome two years earlier. As to his psychological symptoms, the Veteran contended that he had marital problems; "lived a double life" through substances and alcohol use; had troubled relationships which he believed were due to frostbite; and suffered from excruciating headaches. The Veteran attributed his physical maladies to "strenuous stuff" in service. As to employment, the Veteran stated that he cannot get along with his cohort at the juvenile prison where he works. As to his bilateral feet, the Veteran testified his symptoms worsened in service: I started experiencing issues with my feet-let's just say on road marches, when we did the-any road march, I'd just listen to whatever the people would say, put foot powder in your shoes, tie your boots tighter, do this, and make it through. I kept making it through. If I had to put a year on it, it would be after --I would say after basic training because doing all that running and jumping and all that kind of stuff and climbing, well, that's when it really aggravates the problem. In June 2022, VA received an opinion from Occupational Health Solutions, LLC. Here, a physician assistant (PA-C)-consultant reported that the Veteran sustained cold injuries to his extremities during training at Fort Dix, New Jersey. Then, this consultant adopted the VA FNP-C's assessment and described the Veteran's history, without any indication from whence the consultant derived this information. As noted above, the evidence of record contains few STRs and ever fewer military personnel records. This consultant also delved into meteorological data from "nearby Ewing, New Jersey". To support the conclusion that the Veteran incurred Raynaud's syndrome during active-duty service, the consultant grounded a rationale in a U.S. Army Public Heath Power Point. From these observations, the consultant does not appear to have conducted a detailed review or referred to the claims file (with the exception of one July 2019 VAMC July 2019 primary care note) and, thereby, the Veteran's entire post-service medical history. Consequently, the Board finds that this PA-C-consultant's findings, as a totality, warrant negligible consideration vis-à-vis the etiology of the Veteran's claimed cold injuries. Guerrieri v. Brown, 7 Vet. App. 467 (1993) Again, pursuant to the Board's November 2022 remand directives, the Veteran reported for a battery of VA examinations in April and May 2023. In each examination instance, the assigned clinician (or as required, psychologist) followed VA exam protocols. Upon a cold injury residuals examination, a clinician provided a diagnosis of Raynaud's Syndrome (May 2019), indicating manifestations in the "body parts" of the bilateral hands and bilateral feet. After careful contemplation of the totality of evidence, the clinician rendered negative etiological opinions as to the impacted extremities. The clinician offered supporting rationales as follow: As to the bilateral hands, The Veteran has claimed right-hand [and left-hand] cold injuries as being directly related to military service. Based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is scant data supporting a nexus between the current diagnosis of Raynaud's Syndrome and military service. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology. And as to the bilateral feet, The Veteran has claimed right-foot [and left-foot] cold injuries as being directly related to military service. Based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is scant data supporting a nexus between the current diagnosis of Raynaud's Syndrome and military service. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology. Upon a mental disorders (mental health) examination, the psychologist rendered current diagnoses of depressive disorder NOS, anxiety disorder NOS, and unspecified personality disorder. Consequently, the current disability requirement for a psychiatric disability has been met. Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 404 (2020), aff'd sub nom. Martinez-Bodon v. McDonough, 28 F. 4th 1241, 1247 (Fed. Cir. 2022) (a valid DSM-5 diagnosis is required to warrant compensation for a psychiatric disability). After careful contemplation of the totality of evidence, the psychologist rendered negative etiological opinions. As a rationale vis-à-vis direct service connection, the psychologist conveyed that, Claims file reviewed prior to exam today. [The Veteran] reports symptoms that meet DSM-5 criteria for Unspecified Depressive Disorder, Unspecified Anxiety Disorder and Unspecified Personality Disorder. His symptoms are less likely than not incurred during military service due to no data to connect the two found in Veteran's claim file. His self-reported and primary symptoms are inferior interpersonal functioning and difficulty adjusting to civilian life and difficulty maintaining interpersonal relationships and jobs. As a rationale vis-à-vis service connection on a secondary basis, the psychologist articulated that, [The] Veteran does not report symptoms of low back pain in relation to symptoms of anxiety, depression or personality or tinnitus. The Board would be remiss if it failed to mention that the Veteran has not been granted service connection for any low back disorder (based upon any theory of entitlement). Consequently, a grant of service connection for these three diagnosed disabilities as secondary to any low back disorder is not possible as a matter of law. Sabonis v. Brown, 6 Vet. App. 426 (1994) (holding that, where the law is dispositive, the claim must be denied due to an absence of legal entitlement). Upon a headache examination, the clinician rendered a diagnosis of acute intermittent tension headaches. After consideration of the totality of evidence, the clinician rendered a negative etiological opinion. As a rationale vis-à-vis direct service connection, the clinician conveyed that, [The] Veteran has claimed Headache disorder as being directly related to military service. Based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is scant data supporting a nexus between the current diagnosis of Acute/Intermittent Tension Headache, not Chronic and military service. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology. As a rationale vis-à-vis service connection on a secondary basis, the psychologist articulated that, Veteran had no complaints, treatment, or diagnosis of a headache disorder while in service. Veteran reports no current diagnosis or treatment for headaches. Veteran has subjective complaints of symptoms related to headache on exam. Veteran was given diagnosis of Acute Tension Headaches on today's exam. As articulated above-be it direct, secondary, or through any other form of entitlement to service connection, service connection cannot be established without a current disability. Romanowsky, 26 Vet. App. 289. Upon examination of the feet (separately claimed pes planus and plantar fasciitis), the clinician (on two separate forms) rendered diagnoses of bilateral pes planus and bilateral plantar fasciitis. Upon consideration of the evidence of record and examination findings, the clinician rendered negative etiological opinions. As to bilateral pes planus, the clinician reported that, [The] Veteran has claimed Bilateral Pes Planus as being directly related to military service. Based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is scant data supporting a nexus between the current diagnosis of Bilateral Pes Planus and military service. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology. AND The claimed condition [bilateral pes planus], which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. Temporary aggravation is plausible, but there is no evidence of permanent aggravation of the pre-existing Bilateral Pes Planus. A review of the Veteran's C-file is negative for in-service complaints or treatments while in or after service. A thorough review of medical literature fails to support that the pre-existing condition was permanently aggravated by service. A nexus has not been established. As to bilateral plantar fasciitis, the clinician opined that, [The] Veteran has claimed Bilateral Plantar Fasciitis as being directly related to military service. Based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is scant data supporting a nexus between the current diagnosis of Bilateral Plantar Fasciitis and military service. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology. AND The claimed condition [bilateral plantar fasciitis], which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. A review of the C-file is negative for the documentation of bilateral plantar fasciitis as a pre-existing condition. Thus, even though the clinician provided an opinion based upon clear and unmistakable evidence, such an evidentiary standard was inapposite to the Veteran's "soundness" as to this claimed disability as plantar fasciitis was not reported in any way upon induction into active-duty service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b); Wagner, 370 F. 3d 1089; Bagby, 1 Vet. App. 227; VAOGCPREC 3-2003 (July 16, 2003); Horn, 25 Vet. App. 231. Upon a thoracolumbar spine examination, the clinician provided a diagnosis of degeneration of the lumbar intervertebral disc (June 2022). Here, too, the clinician rendered a negative etiological opinion (based upon the totality of relevant evidence). As the clinician conveyed: [The] Veteran has claimed low back disorder as being directly related to military service. Based on review of the available evidence, it is less likely than not that the claimed condition is due to service as there is scant data supporting a nexus between the current diagnosis and military service. Without chronicity during service or after service, a post-service event, illness, or injury is considered to be a more likely etiology. AND The claimed condition is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of Veteran's service-connected condition. Again, the Board observes that the Veteran is service connected for tinnitus at 10 percent effective from December 30, 2016. The Veteran has not been service connected for any other disability, to include degenerative joint disease. Thus, to the extent that the clinician noted degenerative joint disease in the opinion, it is misplaced; however, this notation of degenerative joint disease does not vitiate the probative value of this opinion because, as a matter of law, secondary service connection cannot be established without a primary service-connected disability. Sabonis, 6 Vet. App. 426. Indeed, the clinician's harmless error of noting degenerative joint disease far outweighs the lack of competent supporting evidence to the contrary. Neither the Veteran nor either of his representatives have produced any competent evidence to support the contention that the Veteran's degeneration of the lumbar intervertebral disc has any direct or secondary connexity to active-duty service. Here, the Board notes that the Veteran still ultimately bears some burden of production. 38 U.S.C. § 5107(a); Cromer v. Nicholson, 455 F. 3d 1346 (Fed. Cir. 2006). Moreover, the evidence of record fails to disclose that a competent medical clinician directly reported such a relationship to the Veteran, which, correspondingly, minimizes the probative weight of the Veteran's unsupported claim that his degeneration of the lumbar intervertebral disc has any direct or secondary connexity to active-duty service. 38 C.F.R. § 3.159 (a)(2). As already articulated, the Board has considered the Veteran's lay accounts and hearing testimony carefully, in particular the Veteran's competence to report the diagnosis of a psycho-medical provider. Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007) (a layperson is competent to report a contemporaneous medical diagnosis). To the extent that the Veteran's portions of the Veteran's lay reporting suggest a relationship between the Veteran's current disabilities and active-duty service, this is precisely the type of complex medical issue relating to internal psycho-medical and somatic processes which extend far beyond an immediately observable cause-and-effect relationship as to which lay evidence is simply not competent. Jandreau, 492 F. 3d 1376 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether service connection for any of the Veteran's 9 claimed disabilities is warranted. Rather, the totality of evidence, as extensively discussed herein, persuasively weighs against service connection for any of the 9 claimed disabilities. Consequently, the benefit of the doubt doctrine, see 38?U.S.C. §?5107(b), 38 C.F.R. § 3.102, is therefore not for application as to these 9 service connection claims. Lynch v. McDonough, 21 F. 4th 776, 781-82 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side, or another is the benefit of the doubt doctrine not for application). Therefore, service connection for right foot cold weather injury; left foot cold weather injury; right hand cold weather injury; left hand cold weather injury; bilateral pes planus; bilateral plantar fasciitis; acquired psychiatric disorder; headaches disorder; and low back disorder must all be denied. 10. Entitlement to a TDIU is denied. In order to establish entitlement to a TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The phrase substantially gainful employment has two components: an economic one and a noneconomic one. Ray v. Wilkie, 31 Vet. App. 58 (2019). In assessing the Veteran's ability to secure and follow a substantially gainful occupation, the Board is to consider the Veteran's history, education, skill, and training as well as physical abilities and mental abilities required by the occupation at issue. Such specific physical ability-factors include lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory, and visual. Specific mental ability-factors include memory, concentration, ability to adapt to change, handle work-place stress, getting along with coworkers, and demonstrating reliability and productivity. The regulatory scheme for a TDIU provides both objective and subjective criteria. Hatlestad, 5 Vet. App. 524; VAOPGCPREC 75-91 (Dec. 27, 1991) 57 Fed. Reg. 2317 (1992). The objective criteria, set forth at 38 C.F.R. § § 3.340 (a)(2), provide for a total rating when there is a single disability or a combination of disabilities that results in a 100 percent schedular evaluation. Subjective criteria, set forth at 38 C.F.R. §§ 4.16 (a), provide for a TDIU when, due to service-connected disability, a veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the veteran does not meet the afore-mentioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). Discussion VA received the Veteran's VA Form 21-8940 on August 2, 2022. Here, the Veteran indicated that he had been employed at two juvenile justice facilities and at a student transition and recovery program. The Veteran reported that he had completed 4 years of university study culminating in a bachelor's degree. Otherwise, the Veteran reported that he had no means of income. At the Board hearing, the Veteran testified that. I'm trying to think of what you'd call can't get along in a prison. I don't -my lifestyle does not permit me to work in a prison. I can't--I cannot keep somebody locked up. I feel locked up. So I couldn't work in there [...] I couldn't -couldn't work in the prison. Additionally, the following exchange between the Veteran and his former representative sheds light on the Veteran's employability, employment options, and employment limitations. Representative: So why didn't you go and get a job somewhere else, then, after being a corrections' officer, say, Burger King? Veteran: Okay, I won't use Burger King, but I think I tried to get a job other places. I --that was at a time when computers and resumes were kind of hot over the online but it -it seems like I couldn't go nowhere and get a job. I couldn't -I wasn't -I didn't qualify. I had over 300 resumes and can't get a job. As to his present vocational pursuits, the Veteran reported that he farms because "going to any kind of official function of any kind is [a] headache [that] comes over you". As already reported, the Veteran has one service-connected disability-tinnitus at 10 percent effective from December 30, 2016. Hence, the Veteran has never met schedular criteria for entitlement to a TDIU. Nevertheless, the Board will assess whether the provision of entitlement to a TDIU under the provisions laid out in 38 C.F.R. § 4.16(b) are for application otherwise. In August 2017, the Veteran reported for a VA tinnitus examination. The audiologist noted that the Veteran reported that tinnitus "is moderately to severely bothersome". As to the impact of tinnitus on the conditions of daily life, including the ability to work, the audiologist added that the Veteran stated. The tinnitus zones you out. The tinnitus (low pitched and intense) is always there. It's a rushing/pressure in your head, that directs your attention elsewhere, causes frustration/anxiety/loss of patience. Clearly the Veteran is competent to convey the discernable "rushing" of tinnitus and its other ongoing symptoms. Charles v. Principi, 16 Vet. App. 370, 374 (2002) (observing that "ringing in the ears is capable of lay observation"). The Board does not question the sincerity of the Veteran's belief that tinnitus is frustrating and anxiety-promoting. However, given the Veteran's educational history and breadth of vocational experiences, the Board must consider whether the functional impact of this one service-connected disability raises a reasonable possibility of preventing the Veteran from obtaining and sustaining substantially gainful employment. Withers v. Wilkie, 30 Vet. App. 139 (2018); Snider v. McDonough, 35 Vet. App. 1 (2021). With a college education and professional experience in the field of prison administration, security, juvenile justice, and agriculture, the Veteran possesses a wealth of transferrable skills to a host of professional settings. Clearly, the Veteran possesses skills to perform administrative and "behind the scenes" duties that would not be thwarted by the distraction of tinnitus. The Veteran's command of language and loquacity, exemplified by testimony at two Board hearings, underscore an ability to communicate with other stakeholders. Such language acumen would be invaluable in preparing training materials and administrative guides for the professional sectors in which the Veteran has expertise. Indeed, the Veteran's command of language is an invaluable asset in the contemporary vocational marketplace. The aforementioned August 2017 VA audiologist did not report that tinnitus was productive of total occupational impairment. In this sense, the Veteran has not reported that his unemployability is the result of his one service-connected disability. In accordance with the Court's holding in Ray, the Board has considered the economic and noneconomic components of the Veteran's TDIU claim. Ray, 31 Vet. App. 58. The Board recognizes that the Veteran's service-connected disability presents limitations. This disability however does not preclude occupational pursuits where there are opportunities for breaks when bouts of "rushing" occur. Many employers offer reasonable accommodations pursuant to the Americans with Disabilities Act, as amended (ADAAA), to allow for downtime due to a disability. In the Veteran's case, it would have been more than feasible for an employer to provide breaks in quiet settings where the Veteran could rest during onslaughts of tinnitus. Thus, the Board finds that the Veteran's education and professional experience are more-than-sufficient for the Veteran to obtain and sustain substantially gainful employment. Withers, 30 Vet. App. 139. Lest the Veteran feel that he has not been compensated for his service-connected disability, the Board notes that the rating schedule was created as a guide to evaluating disabilities resulting from all types of diseases and injuries encountered, and the percentage ratings that are assigned represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. The Board has considered the totality of evidence carefully. The Veteran has offered testimony as to his perceived annoyance, distraction, and anxiety caused by tinnitus; nevertheless, the evidence is not at least in relative equipoise as to whether this lay quantum of annoyance, distraction, and anxiety, even as a totality, raises a "reasonable possibility" that the Veteran has been rendered unemployable by dint of his one service-connected disability. Consequently, the Board finds that referral for extraschedular consideration to the Director of Compensation Service is not warranted. Snider, 35 Vet. App. 1. Thus, the weight of competent and probative evidence is not in relative equipoise as to entitlement to a TDIU on an extraschedular basis. The Veteran's claim must be denied, and there remains no doubt to resolve. Lynch, 21 F. 4th 776; 38 U.S.C. § 5107 John R. Doolittle, II Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. J. Komins, 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.