series: legacy

judge_norm: A P SIMPSON

judge_role: Veterans Law Judge

disposition: denied

benefit: tdiu

condition: ptsd

text:
��Citation Nr: 18103000

Decision Date: 05/17/18	Archive Date: 05/16/18

DOCKET NO. 09-08 515

DATE:	May 17, 2018

ORDER

As new and material evidence has not been received, the claim to reopen a previously denied claim of entitlement to service connection for a bilateral hand disability, to include as secondary to service-connected residuals of shell fragment wounds (SFWs) to the left forearm, left wrist, left leg, and right forearm, or a neck disability, is denied.

Entitlement to service connection for moderate left carpal tunnel syndrome and mild ulnar neuropathy at the wrist and elbow, to include as secondary to a service-connected left shoulder disability, is denied.

Entitlement to service connection for a left leg disability (claimed as neuropathy of the left leg), to include as secondary to service-connected residuals of SFWs to the left forearm, left wrist, left leg and right forearm, or a neck disability is denied.

Entitlement to service connection for a neck disability, to include as secondary to a left shoulder disability and traumatic brain injury (TBI), is denied.

Entitlement to service connection for a bilateral foot disability, to include as secondary to a service-connected left shoulder disability and traumatic brain injury (TBI), is denied.

Entitlement to service connection for an eye disability, to include as secondary to a service-connected left shoulder disability, is denied.

Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities, is denied.

Entitlement to service connection for irritable bowel syndrome (IBS), to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities, is denied.

Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected posttraumatic stress disorder (PTSD), SFWs, or medication taken for service-connected disabilities, is denied.

Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities, is denied.

Entitlement to an increased disability rating in excess of 20 percent for residuals of SFW, muscle group II, left shoulder, with retained foreign body is denied.

Entitlement to an increased disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to September 7, 2011, and in excess of 50 percent thereafter is denied.

The issue of entitlement to an effective date prior to September 7, 2011 for the grant of a total disability rating based on individual unemployability is remanded.

The issue of entitlement to an effective date prior to September 7, 2011 for the grant of Dependents Education Assistance benefits is remanded.

FINDINGS OF FACT

1. A July 2002 rating decision denied the Veteran s claim of entitlement to service connection for a bilateral hand disability, to include as secondary to service-connected residuals of SFWs to the left forearm, left wrist, left leg, and right forearm.  The Veteran was properly notified of this determination and his appeal rights; however, the Veteran did not appeal that decision or submit new and material evidence within the one-year appeal period.

2. Evidence received since the July 2002 rating decision is either previously of record, cumulative or redundant of evidence already of record, or does not relate to a previously unestablished fact necessary to substantiate the previously denied claim of entitlement to service connection for a bilateral hand disability, previously claimed as secondary to service-connected residuals of SFWs to the left forearm, left wrist, left leg, and right forearm, and now claimed as secondary to a neck disability.

3. Moderate left carpal tunnel syndrome and mild ulnar neuropathy at the wrist and elbow did not have their onset during active service or within one year of service discharge and are not otherwise related to active service, to include as secondary to a service-connected left shoulder disability.

4. A left leg disability (claimed as neuropathy of the left leg) did not have its onset during active service or within one year of service discharge and is not otherwise related to active service, to include as secondary to service-connected residuals of SFWs to the left forearm, left wrist, left leg and right forearm, or a neck disability.

5. A neck disability did not have its onset during active service or within one year of service discharge and is not otherwise related to active service, to include as secondary to a left shoulder disability and TBI.

6. A bilateral foot disability did not have its onset during active service or within one year of service discharge and is not otherwise related to active service, to include as secondary to a service-connected left shoulder disability and TBI.

7. An eye disability did not have its onset during active service and is not otherwise related to active service, to include as secondary to a service-connected left shoulder disability.

8. Hypertension did not have its onset during active service or within one year of service discharge and is not otherwise related to active service, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.

9. IBS did not have its onset during active service and is not otherwise related to active service, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.

10. GERD did not have its onset during active service and is not otherwise related to active service, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.

11. ED did not have its onset during active service and is not otherwise related to active service, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.

12. For the entire period on appeal, the Veteran s residuals of a shell fragment wound, muscle group II, left shoulder, with retained foreign body, have been manifested by no worse than a moderate muscle disability.

13. Prior to September 7, 2011, the Veteran s PTSD was manifested by psychiatric symptoms all of which are most nearly approximated by no worse than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal).

14. From September 7, 2011, the Veteran s PTSD was manifested psychiatric symptoms all of which are most nearly approximated by no worse than occupational and social impairment with reduced reliability and productivity.

CONCLUSIONS OF LAW

1. The July 2002 rating decision that denied the Veteran s claim of entitlement to service connection for a bilateral hand disability, to include as secondary to service-connected residuals of shell fragment wounds to the left forearm, left wrist, left leg, and right forearm, is final.  38 U.S.C. � 7105 (2012); 38 C.F.R. �� 20.302, 20.1103 (2017).

2. New and material evidence sufficient to reopen the Veteran s claim of entitlement to service connection for a bilateral hand disability, to include as secondary to service-connected residuals of shell fragment wounds to the left forearm, left wrist, left leg, and right forearm, or a neck disability, has not been added to the record.  38 U.S.C. � 5108 (2012); 38 C.F.R. � 3.156(a) (2017).

3. The criteria for service connection for moderate left carpal tunnel syndrome and mild ulnar neuropathy at the wrist and elbow, to include as secondary to a service-connected left shoulder disability, have not been met.  38 U.S.C. �� 1101, 1110, 1112, 5107 (2012); 38 C.F.R. �� 3.102, 3.303, 3.307, 3.309, 3.310 (2017).

4. The criteria for service connection for a left leg disability (claimed as neuropathy of the left leg), to include as secondary to service-connected residuals of shell fragment wounds to the left forearm, left wrist, left leg and right forearm, or a neck disability, have not been met.  38 U.S.C. �� 1101, 1110, 1112, 5107 (2012); 38 C.F.R. �� 3.102, 3.303, 3.307, 3.309, 3.310 (2017).

5. The criteria for service connection for a neck disability, to include as secondary to a left shoulder disability and TBI, have not been met.  38 U.S.C. �� 1101, 1110, 1112, 5107 (2012); 38 C.F.R. �� 3.102, 3.303, 3.307, 3.309, 3.310 (2017).

6. The criteria for service connection for a bilateral foot disability, to include as secondary to a service-connected left shoulder disability and TBI, have not been met.  38 U.S.C. �� 1101, 1110, 1112, 5107 (2012); 38 C.F.R. �� 3.102, 3.303, 3.307, 3.309, 3.310 (2017).

7. The criteria for service connection for an eye disability, to include as secondary to a service-connected left shoulder disability, have not been met.  38 U.S.C. �� 1110, 5107 (2012); 38 C.F.R. �� 3.102, 3.303, 3.310 (2017).

8. The criteria for service connection for hypertension, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities, have not been met.  38 U.S.C. �� 1101, 1110, 1112, 5107 (2012); 38 C.F.R. �� 3.102, 3.303, 3.307, 3.309, 3.310 (2017).

9. The criteria for service connection for IBS, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities, have not been met.  38 U.S.C. �� 1110, 5107 (2012); 38 C.F.R. �� 3.102, 3.303, 3.310 (2017).

10. The criteria for service connection for GERD, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities, have not been met.  38 U.S.C. �� 1110, 5107 (2012); 38 C.F.R. �� 3.102, 3.303, 3.310 (2017).

11. The criteria for service connection for ED, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities, have not been met.  38 U.S.C. �� 1110, 5107 (2012); 38 C.F.R. �� 3.102, 3.303, 3.310 (2017).

12. The criteria for an increased disability rating in excess of 20 percent for residuals of a shell fragment wound, muscle group II, left shoulder, with retained foreign body, have not been met.  38 U.S.C. �� 1155, 5107 (2012); 38 C.F.R. �� 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.73, Diagnostic Code (DC) 5302 (2017).

13. The criteria for an increased disability rating in excess of 30 percent for PTSD prior to September 7, 2011, and in excess of 50 percent thereafter have not been met.  38 U.S.C. �� 1155, 5107 (2012); 38 C.F.R. �� 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, DC 9411 (2017).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from November 1965 to November 1967.

The Veteran s claim to reopen a previously denied claim of entitlement to service connection for a bilateral hand disability; claims of entitlement to service connection for moderate left carpal tunnel syndrome and mild ulnar neuropathy at the wrist and elbow, a left leg disability, a neck disability, a bilateral foot disability, and an eye disability; and claims of entitlement to increased ratings for a left shoulder SFW residuals and PTSD, were all remanded by the Board in May 2013 for additional development, including to obtain relevant VA opinions regarding a theory of secondary service connection and identified Vet Center treatment records.  Notably, VA obtained the requested opinions; however, the Veteran did not, and has not subsequently, authorized VA to obtain the identified Vet Center treatment records.  See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991).  As such, the Board finds that there has been substantial compliance with prior remand directives, such that the matters are properly returned to the Board for adjudication.  See Stegall v. West, 11 Vet. App. 268 (1998).  Similarly, the Veteran s claims of entitlement to service connection for GERD, IBS, ED, and hypertension, and entitlement to earlier effective dates for the grants of TDIU and DEA benefits, were remanded by the Board in January 2016 for additional development, including relevant VA opinions regarding a theory of secondary service connection.  As the requested development has been completed, the matters are now properly returned to the Board for adjudication.  See id.

The Board has thoroughly reviewed all the evidence in the Veteran s claims file.  Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence).  The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, regarding the Veteran s claim on appeal.  The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein.  See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant).

New and Material Evidence

1. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for a bilateral hand disability, to include as secondary to service-connected residuals of shell fragment wounds to the left forearm, left wrist, left leg, and right forearm, or a neck disability

Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered.  38 U.S.C. � 7105(c) (2012).  However, a claim on which there is a final decision may be reopened if new and material evidence is submitted.  38 U.S.C. � 5108 (2012).

New evidence is defined as existing evidence not previously submitted to agency decisionmakers, while material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  38 C.F.R. � 3.156(a) (2017).  New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.  Id.

The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low.  See Shade v. Shinseki, 24 Vet. App. 110 (2010).  The assertion of a new theory of entitlement to service connection for the same disease or injury that was previously the subject of a final decision does not constitute a new distinct claim for benefits, see Boggs v. Peake, 520 F.3d 1330, 1336-37 (Fed. Cir 2008); however, evidence offered in support of a new theory of entitlement can be sufficient to warrant reopening of the claim if it meets the definitions of new and material evidence.  Id.

The Veteran s claim of entitlement to service connection for a bilateral hand disability, to include as secondary to service-connected residuals of shell fragment wounds to the left forearm, left wrist, left leg, and right forearm, was previously denied within a July 2002 rating decision.  The Veteran was notified of this determination in an August 2002 letter, which included his appeal rights; however, the Veteran did not appeal that decision or submit new and material evidence within the one-year appeal period; therefore, the July 2002 rating decision is final.  38 U.S.C. � 7105; 38 C.F.R. �� 20.302, 20.1103 (2017).

Since the prior final July 2002 rating decision, the Veteran has continued to assert a secondary theory of service connection, including now that his claimed bilateral hand disability is secondary to a neck disability.  Evidence added to the record includes treatment records, which document the Veteran s paresthesias of the bilateral hands, which are secondary to cervical osteoarthritis.  Notably, however, as discussed further herein, the Veteran is not service-connected for a cervical spine disability.  Thus, while such evidence is new, in that it was not of record at the time of the previous July 2002 rating decision, it is not material because it does not relate to an unestablished fact necessary to substantiate the Veteran s claim of entitlement to service connection for a bilateral hand disability, namely that such condition is related to the Veteran s active service or is secondary to service-connected residuals of shell fragment wounds to the left forearm, left wrist, left leg, and right forearm, or a neck disability.  38 C.F.R. � 3.156(a).  Given that the evidence submitted is not both new and material, reopening of the Veteran s claim of entitlement to service connection for a bilateral hand condition is not warranted.  38 U.S.C. � 5108; 38 C.F.R. � 3.156.

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service.  See 38 U.S.C. � 1110 (2012); 38 C.F.R. � 3.303(a) (2017).  To establish a right to compensation for a present disability, a Veteran must show:  (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.   Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

Service connection may also be granted on a secondary basis for a disability which is  proximately due to or the result of a service-connected disease or injury.   38 C.F.R. � 3.310(a) (2017).  Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation.  Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. � 3.310(b).

For certain chronic disorders, including arthritis and other organic diseases of the nervous system, service connection may be granted on a presumptive basis if the disease is manifested to a compensable degree within one year following service discharge.  38 U.S.C. �� 1101, 1112 (2012); 38 C.F.R. �� 3.307(a)(3), 3.309(a) (2017).  Additionally, for chronic diseases defined by 38 C.F.R. � 3.309(a) and shown in service or by a continuity of symptoms after service, the disease shall be presumed to have been incurred in service.  38 C.F.R. � 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  Even where service connection cannot be presumed, service connection may still be established on a direct basis.  See Stefl, 21 Vet. App. at 124-25; see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994).

2. Entitlement to service connection for moderate left carpal tunnel syndrome and mild ulnar neuropathy at the wrist and elbow, to include as secondary to a service-connected left shoulder disability

The Veteran claims entitlement to service connection for moderate left carpal tunnel syndrome and mild ulnar neuropathy at the wrist and elbow, to include as secondary to a service-connected left shoulder disability.

Service treatment records do not document any complaints, treatment, or diagnosis of moderate left carpal tunnel syndrome and mild ulnar neuropathy at the wrist and elbow.  A November 1965 enlistment documents a normal clinical evaluation of the Veteran s left upper extremity, without noted defects or diagnoses.  Although a September 1966 treatment record documents shrapnel wounds to the Veteran s upper extremities, the physician specifically noted there was no artery or nerve involvement.  Significantly, a November 1967 separation examination also documents a normal clinical evaluation of the Veteran s left upper extremity, without noted defects or diagnoses.

Post-service treatment records document a November 1974 x-ray of the Veteran s left wrist that was unremarkable.  In January 2003, the Veteran reported a fifteen-year history of gout with painful joints.  September 2007 electromyography (EMG) testing of the Veteran s left upper extremity documents moderate focal neuropathy of the left median nerve at the wrist, consistent with carpal tunnel entrapment, mild neuropathy of the left ulnar nerve at the wrist, consistent with compression or entrapment, and mild focal neuropathy of the left ulnar nerve at the elbow, consistent with cubital tunnel entrapment.

Upon VA examination in October 2008, the VA examiner diagnosed moderate left carpal tunnel syndrome and mild ulnar neuropathy at the wrist and elbow, with unknown cause and without radicular type symptoms.  The examiner stated that such neurological findings could not be tied to the Veteran s service-connected shrapnel injuries; rather, they likely all represented degenerative changes of the spine and entrapment neuropathies as found on EMG testing.

Upon VA examination in May 2017, a VA examiner noted that service treatment records did not document a chronic left wrist or elbow condition during active service or within one year of service discharge.  Therefore, the examiner opined that it was less likely as not that a current left wrist or elbow condition was related to active service; rather, it was more likely due to normal wear and tear and the Veteran s advanced age.  The examiner further stated that it was less likely as not that a current left wrist or elbow condition was aggravated by a service-connected left shoulder disability, as there was no aggravation due to activity observed upon examination and no medical evidence to support that his service-connected disabilities put undue stress on the Veteran s left wrist or left elbow.  Rather, the examiner noted that it was as likely as not that the Veteran s current left wrist and elbow conditions were related to normal wear and tear given a twenty-year career as an electrician and advanced age.

The Board notes that the May 2017 VA examiner s opinion is of greatest probative value in the context of the Veteran s claim, as the opinion properly considered the Veteran s medical history, and included a reasoned rationale, which concluded that the Veteran s condition was likely due to wear and tear, a twenty-year post-service career as an electrician, and the normal aging process.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).  Significantly, there are no objective medical opinions to weigh against the negative nexus opinion of the March 2017 VA examiner.

The Veteran s lay statements of record are probative evidence insofar as they report observable symptomatology, see Layno v. Brown, 6 Vet. App. 465, 469 (1994); however, to the extent that the Veteran asserts a nexus between his claimed moderate left carpal tunnel syndrome and mild ulnar neuropathy at the wrist and elbow and his active service, to include as secondary to include as secondary to a service-connected left shoulder disability, they are afforded less probative value, as the Veteran is not shown to possess medical expertise.  See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).

In conclusion, the Board finds that the preponderance of the evidence is against the Veteran s claim of entitlement to service connection for moderate left carpal tunnel syndrome and mild ulnar neuropathy at the wrist and elbow, to include as secondary a service-connected left shoulder disability.  Moreover, as there is no probative evidence that moderate left carpal tunnel syndrome and mild ulnar neuropathy at the wrist and elbow first had onset during active service or within one year of service discharge, presumptive service connection is not warranted.  38 U.S.C. �� 1101, 1112; 38 C.F.R. �� 3.307(a)(3), 3.309(a).  Given the above, there is no reasonable doubt to be resolved, and the claim must be denied.  38 U.S.C. � 5107(b) (2012); 38 C.F.R. � 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

3. Entitlement to service connection for a left leg disability (claimed as neuropathy of the left leg), to include as secondary to service-connected residuals of shell fragment wounds to the left forearm, left wrist, left leg and right forearm, or a neck disability

The Veteran also claims entitlement to service connection for a left leg disability (claimed as neuropathy of the left leg), to include as secondary to service-connected residuals of shell fragment wounds to the left forearm, left wrist, left leg, and right forearm, or a neck disability.

Service treatment records do not document any complaints, treatment, or diagnosis of a left leg disability.  A November 1965 enlistment documents a normal clinical evaluation of the Veteran s left lower extremity, without noted defects or diagnoses.  Although a September 1966 treatment record documents shrapnel wounds to the Veteran s left hip and leg, the physician specifically noted there was no artery or nerve involvement.  Significantly, a November 1967 separation examination also documents a normal clinical evaluation of the Veteran s left lower extremity, without noted defects or diagnoses.

In September 1974, the Veteran complained of pain in his left hip and thigh; this was assessed as a prior gunshot wound with retained shell fragments.  Years later, in October 1999, the Veteran complained of left sided sciatic pain, which he worried was related to an old shrapnel wound in his left hip; however, a VA physician noted his complaints were probably related to disc deterioration and herniation shown on MRI.  In May 2009, the Veteran complained of a twenty-year history of progressively worsening left sciatica.

Upon VA examination in October 2008, a VA examiner concluded that diagnostic EMG testing suggested a mild polyneuropathy in the Veteran s lower extremities, with unknown cause and without radicular type symptoms.  The examiner stated that such neurological findings could not be tied to the Veteran s service-connected shrapnel injuries; rather, they likely all represented degenerative changes of the spine and entrapment neuropathies as found on EMG testing.

Upon VA examination in May 2017, a VA examiner diagnosed degenerative arthritis of the left knee from 2007, which was less likely as not related to or aggravated by active service.  The examiner noted that service treatment records did not document a left leg condition during active service or within one year of discharge.  Rather, the examiner concluded that the Veteran s left leg condition was more likely due to normal wear and tear from his twenty-year post-service occupational history and the Veteran s advanced age over seventy years old.  Additionally, the examiner noted that upon examination there was no undue stress, aggravation, or altered gait resulting from the Veteran s service-connected residuals of shell fragment wounds to the left forearm, left wrist, left leg and right forearm; therefore, it was less likely as not that the Veteran s left leg condition was proximately due to, the result of, or aggravated beyond its natural progression by his service-connected disabilities.  Again, the examiner opined that it was more likely due to normal wear and tear and the Veteran s advanced age.

The Board notes that the May 2017 VA examiner s opinion is of greatest probative value in the context of the Veteran s claim, as the opinion properly considered the Veteran s medical history, and included a reasoned rationale, which concluded that the Veteran s condition was likely due to wear and tear and the normal aging process.  See Nieves-Rodriguez, 22 Vet. App. at 304.  Significantly, there are no objective medical opinions to weigh against the negative nexus opinion of the March 2017 VA examiner.

The Veteran s lay statements of record are probative evidence insofar as they report observable symptomatology, see Layno, 6 Vet. App. at 469; however, to the extent that the Veteran asserts a nexus between his claimed bilateral shoulder peripheral neuropathy and his active service, to include as secondary to cervical spine arthritis, they are afforded less probative value, as the Veteran is not shown to possess medical or orthopedic expertise.  See Jandreau, 492 F.3d at 1376-77.

In conclusion, the Board finds that the preponderance of the evidence is against the Veteran s claim of entitlement to service connection for a left leg disability (claimed as neuropathy of the left leg), to include as secondary to service-connected residuals of shell fragment wounds to the left forearm, left wrist, left leg, and right forearm, or a neck disability.  Notably, as the Board has herein denied service connection for a neck disability, secondary service connection for the Veteran s claimed left leg disability as secondary to the claimed neck disability is not warranted as a matter of law.  38 C.F.R. � 3.310.  Moreover, as there is no probative evidence that a neurological left leg disability first had onset during active service or within one year of service discharge, presumptive service connection is not warranted.  38 U.S.C. �� 1101, 1112; 38 C.F.R. �� 3.307(a)(3), 3.309(a).  Given the above, there is no reasonable doubt to be resolved, and the claim must be denied.  38 U.S.C. � 5107(b); 38 C.F.R. � 3.102; Gilbert, 1 Vet. App. 49 (1990).

4. Entitlement to service connection for a neck disability, to include as secondary to a left shoulder disability and traumatic brain injury (TBI)

The Veteran claims entitlement to service connection for a neck disability, to include as secondary to a left shoulder disability and TBI.

Service treatment records do not document complaints, treatment, or diagnosis of a neck or cervical spine disability.  A November 1965 enlistment examination and a November 1967 separation examination each document normal clinical evaluations of the Veteran s spine, without noted defects or diagnoses.

Post-service VA treatment records from November 2006 document a cervical spine x-ray that showed degenerative disc disease primarily at C5-C6 with bilateral uncinate hypertrophy and foramina narrowing at C5-C7 and anterior spondylosis from C3-C7.  In July 2007, the Veteran was noted to have degenerative disease of the neck, which probably accounted for pain in his left fingertips.  An August 2007 MRI documents early acquired cervical C5-C6 and borderline stenosis at C6-C7.  A September 2007 EMG study documented no electrodiagnostic evidence of left cervical radiculopathy.

Upon VA joints examination in October 2007, the Veteran reported neck pain radiating into his shoulders and upper extremities in the past year.  Notably, a treatment note from later that same month documents that the Veteran s severe neck pain from three to four weeks before had resolved and he was no longer limited by neck pain.

Private physical therapy records from November 2008 document the Veteran s report of increasing neck pain for some time, which he related to an injury during active service in Vietnam; however, he also noted that his neck pain began to get serious about four years before.

Upon VA examination in August 2009, the Veteran reported constant neck pain, with flare ups of pain.  He stated that his neck problems began about 10 years before.  An MRI showed degenerative changes in the form of disk bulging and osteoarthritis with neural foraminal narrowing at seven levels, with some mild central canal stenosis.

In May 2017, a VA examiner diagnosed degenerative arthritis of the cervical spine.  However, following a review of the claims file, the examiner noted that the Veteran s service treatment records did not document a chronic neck condition during active service or within one year of discharge.  As such, the examiner opined that it was less likely as not that the Veteran s current neck condition was related to active service.  Additionally, the examiner noted that there was no medical evidence to support that the Veteran s current neck condition was caused by, proximately due to, or aggravated by his service-connected conditions; rather, the examiner opined that it was more likely due to normal wear and tear, overuse during a long career as an electrician, and advanced age.

The Board notes that the May 2017 VA examiner s opinion is of greatest probative value in the context of the Veteran s claim, as the opinion properly considered the Veteran s medical history, and included a reasoned rationale, which concluded that the Veteran s condition was due to wear and tear and the normal aging process.  See Nieves-Rodriguez, supra.  Significantly, there are no objective medical opinions to weigh against the negative nexus opinion of the May 2017 VA examiner.

The Veteran s lay statements of record are probative evidence insofar as they report observable symptomatology, see Layno, supra; however, to the extent that the Veteran asserts a nexus between his current neck disability and his active service, to include as secondary to a service-connected left shoulder disability or TBI, they are afforded less probative value, as the Veteran is not shown to possess medical expertise.  See Jandreau, supra.

Additionally, the Board is mindful that the post-service treatment records documenting cervical spine arthritis are dated nearly 40 years after service discharge; such a lengthy time interval between service and the earliest post-service clinical documentation of the disability is of itself a factor for consideration against a finding that the disability is related to service.  See Maxson v. Gober, 230 F.3d 330 (Fed. Cir. 2000).  As there is no probative evidence that cervical spine arthritis first had onset during active service or within one year of service discharge, presumptive service connection is not warranted.  38 U.S.C. �� 1101, 1112; 38 C.F.R. �� 3.307(a)(3), 3.309(a).

In conclusion, the Board finds that the preponderance of the evidence is against the Veteran s claim of entitlement to service connection for a neck disability, to include as secondary to a service-connected left shoulder disability or TBI.  As such, there is no reasonable doubt to be resolved, and the claim must be denied.  38 U.S.C. � 5107(b); 38 C.F.R. � 3.102; Gilbert, supra.

5. Entitlement to service connection for a bilateral foot disability, to include as secondary to a service-connected left shoulder disability and traumatic brain injury (TBI)

The Veteran claims entitlement to service connection for a bilateral foot disability, to include as secondary to a left shoulder disability and TBI.

Service treatment records do not document complaints, treatment, or diagnosis of a bilateral foot disability.  A November 1965 enlistment examination and a November 1967 separation examination each document normal clinical evaluations of the Veteran s lower extremities and feet, without noted defects or diagnoses.

Post-service VA treatment records from October 2008 document EMG testing, which revealed that the Veteran s lower extremities were largely within normal limits, though minor findings suggested a mild polyneuropathy with unknown cause.  The physician did not see any evidence to suggest radicular type symptoms, and he stated that he could not tie any of the neurological findings to the Veteran s shrapnel injuries from the past; rather, he stated that they likely all represented degenerative changes of the spine and entrapment neuropathies as found on EMG testing.

Notably, there is no probative medical evidence of record, which documents a nexus between the Veteran s claimed bilateral foot disability and his active service, to include a service-connected left shoulder disability and TBI.

The Veteran s lay statements of record are probative evidence insofar as they report observable symptomatology, see Layno, supra; however, to the extent that the Veteran asserts a nexus between a current bilateral foot disability and his active service, to include as secondary to a service-connected left shoulder disability or TBI, they are afforded less probative value, as the Veteran is not shown to possess medical expertise.  See Jandreau, supra.

The Board is mindful that the post-service treatment records documenting bilateral foot neurological symptoms are dated nearly 40 years after service discharge; such a lengthy time interval between service and the earliest post-service clinical documentation of the disability is of itself a factor for consideration against a finding that the disability is related to service.  See Maxson, 230 F.3d 330.  As there is no probative evidence that a bilateral foot neurological disability first had onset during active service or within one year of service discharge, presumptive service connection is not warranted.  38 U.S.C. �� 1101, 1112; 38 C.F.R. �� 3.307(a)(3), 3.309(a).

In conclusion, the Board finds that the preponderance of the evidence is against the Veteran s claim of entitlement to service connection for a bilateral foot disability, to include as secondary to a service-connected left shoulder disability or TBI.  As such, there is no reasonable doubt to be resolved, and the claim must be denied.  38 U.S.C. � 5107(b); 38 C.F.R. � 3.102; Gilbert, supra.

6. Entitlement to service connection for an eye disability, to include as secondary to a service-connected left shoulder disability

The Veteran claims entitlement to service connection for an eye disability, to include as secondary to a left shoulder disability.

Service treatment records do not document complaints, treatment, or diagnosis of an eye disability.  A November 1965 enlistment examination and a November 1967 separation examination each document normal clinical evaluations of the Veteran s eyes, without noted defects or diagnoses.

Post-service VA treatment records from February 1992 and September 2000 document relevant diagnoses of refractive error, presbyopia, right eye glaucoma, and nuclear sclerotic cataract.  July 2001 VA treatment records document the Veteran s history of Bell s palsy affecting his right eye.

Upon VA examination in May 2017, the VA examiner reviewed the Veteran s claims file and conducted a physical examination of the Veteran s eyes.  Following the examination, the examiner diagnosed right side Bell s palsy, lagophthalmus (secondary to Bell s palsy) of the right lower eyelid, right eye exposure keratitis, bilateral nuclear cataracts, bilateral pinguecula, bilateral arcus senilis, and bilateral ocular hypertension.  Ultimately, the examiner opined that the Veteran s claimed eye disability was less likely than not incurred in or caused by active service, and less likely than not proximately due to or the result of his service connected left shoulder condition, as there was no evidence within service treatment records of an eye injury following the in-service explosion that caused the Veteran s left shoulder injury; rather, the Veteran s claimed eye conditions all developed years after the incident.

The Board notes that the May 2017 VA examiner s opinion is of greatest probative value in the context of the Veteran s claim, as the opinion properly considered the Veteran s medical history, and included a reasoned rationale.  See Nieves-Rodriguez, supra.  Significantly, there are no objective medical opinions to weigh against the negative nexus opinion of the May 2017 VA examiner.  Indeed, there is no probative medical evidence of record, which documents a nexus between the Veteran s claimed eye disability and his active service, to include a service-connected left shoulder disability.

The Veteran s lay statements of record are probative evidence insofar as they report observable symptomatology, see Layno, supra; however, to the extent that the Veteran asserts a nexus between a current eye disability and his active service, to include as secondary to a service-connected left shoulder disability, they are afforded less probative value, as the Veteran is not shown to possess medical expertise.  See Jandreau, supra.

In conclusion, the Board finds that the preponderance of the evidence is against the Veteran s claim of entitlement to service connection for an eye disability, to include as secondary to a service-connected left shoulder disability.  As such, there is no reasonable doubt to be resolved, and the claim must be denied.  38 U.S.C. � 5107(b); 38 C.F.R. � 3.102; Gilbert, supra.

7. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities

The Veteran claims entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.

Service treatment records do not document complaints, treatment, or diagnosis of hypertension.  A November 1965 enlistment examination and a November 1967 separation examination each document normal clinical evaluations of the Veteran s eyes, without noted defects or diagnoses.

Upon VA examination in June 2012, the Veteran reported that he was diagnosed with hypertension in the late 1980s.  Following the examination, and review of the claims file, the VA examiner opined that the Veteran s hypertension was less likely than not related to his service-connected conditions or treatment for such conditions.  The examiner noted that the Veteran s service-connected conditions can cause episodic transient blood pressure elevation, but not sustained blood pressure elevation in the absence of end organ damage, as in the Veteran s case.  The examiner further concluded that medication taken for service-connected conditions did not cause the Veteran s hypertension, as the medical record documented an onset of hypertension long before the Veteran began medication treatment for his service-connected disabilities.  The examiner again noted that there would need to be end organ damage from the service-connected disabilities or treatment for such conditions in order to cause hypertension; however, the medical record did not support this, and therefore, there was no relationship between the Veteran s current hypertension and his service-connected disabilities, including medication treatment for such conditions.  The examiner reviewed submitted reports about PTSD resulting in hypertension; however, he noted that his opinion was unchanged, as there were conflicting VA studies where cardiovascular illness could not directly be related to PTSD.

More recently, upon VA examination in June 2016, the same VA examiner again opined that the Veteran s hypertension was less likely than not proximately due to or the result of his service-connected conditions.  The examiner based this opinion on a review of the claims file, Veteran s medical history, and medical literature, all of which showed that the Veteran s hypertension was primary and therefore without an etiology.  The examiner acknowledged that mood disorders were a risk factor for hypertension, but he noted that these were not causative for essential hypertension; therefore, the Veteran s essential hypertension was less likely than not related to his PTSD.  The examiner noted that the studies submitted by the Veteran in support of his claim were isolated studies; rather, a review of presently accepted literature (Up To Date), which was based on multiple medical studies as opposed to isolated studies presented by Veteran, did not document a relationship between the Veteran s hypertension and his service-connected conditions.

The Board notes that the June 2012 and June 2016 VA examiner s opinions are of greatest probative value in the context of the Veteran s claim, as the opinions properly considered the Veteran s medical history, the submitted medical literature, and included a reasoned rationale.  See Nieves-Rodriguez, supra.  Significantly, there are no objective medical opinions to weigh against the negative nexus opinions of the VA examiner.  Indeed, there is no probative medical evidence of record, which documents a nexus between the Veteran s claimed hypertension his active service, to include service-connected PTSD, SFWs, or medication taken for service-connected disabilities.

The Veteran s lay statements of record are probative evidence insofar as they report observable symptomatology, see Layno, supra; however, to the extent that the Veteran asserts a nexus between hypertension and his active service, to include as secondary to a service-connected disability or related treatment, they are afforded less probative value, as the Veteran is not shown to possess medical expertise.  See Jandreau, supra.

The medical studies submitted by the Veteran regarding a possible connection between hypertension and PTSD have been considered; however, the Board finds that such evidence is of a general nature and it does not discussed the specific facts of the Veteran s case; therefore, it is of limited probative value and is outweighed by the VA examiner s negative nexus opinions discussed above.  See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also Sacks v. West, 11 Vet. App. 314, 317 (1998).  Additionally, the VA examiner stated that the isolated studies submitted by the Veteran are outweighed by a review of Up To Date, which is presently accepted medical literature based upon multiple medical studies.

In conclusion, the Board finds that the preponderance of the evidence is against the Veteran s claim of entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.  As such, there is no reasonable doubt to be resolved, and the claim must be denied.  38 U.S.C. � 5107(b); 38 C.F.R. � 3.102; Gilbert, supra.

8. Entitlement to service connection for irritable bowel syndrome (IBS), to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities

The Veteran claims entitlement to service connection for IBS, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.

Service treatment records do not document complaints, treatment, or diagnosis of IBS.  A November 1965 enlistment examination and a November 1967 separation examination each document normal clinical evaluations of the gastrointestinal system, without noted defects or diagnoses.

Post-service VA treatment records document a January 2001 diagnosis of diverticuli of the sigmoid colon.

Upon VA examination in May 2010, the Veteran reported irritable bowel symptoms for the past 10 years, with altered bowel movement but without a formal diagnosis of IBS.  The examiner ultimately diagnosed IBS but concluded that IBS was not related to PTSD.  The examiner stated that IBS was a condition with an unknown cause and without a specific etiology; he noted that some studies suggested a psychological component with gastrointestinal function, but stated that there were no consistent studies, which directly linked PTSD to IBS.

In June 2016, a VA examiner opined that the Veteran s IBS was less likely than not proximately due to or the result of the Veteran s service-connected disabilities.  The examiner stated, based upon a review of presently accepted medical literature including Up To Date, that IBS did not have a known etiology; therefore, it was unrelated to PTSD.  The examiner stated that the medical studies submitted by the Veteran in support of his claim were isolated studies, as opposed to the presently accepted evidence based upon multiple medical studies.

The Board notes that the May 2010 and June 2016 VA opinions are of greatest probative value in the context of the Veteran s claim, as the opinions properly considered the Veteran s medical history, the submitted medical literature, and included a reasoned rationale.  See Nieves-Rodriguez, supra.  Significantly, there are no objective medical opinions to weigh against the negative nexus opinions.  Indeed, there is no probative medical evidence of record, which documents a nexus between the Veteran s claimed IBS and his active service, to include service-connected PTSD, SFWs, or medication taken for service-connected disabilities.

The Veteran s lay statements of record are probative evidence insofar as they report observable symptomatology, see Layno, supra; however, to the extent that the Veteran asserts a nexus between IBS and his active service, to include as secondary to a service-connected disability or related treatment, they are afforded less probative value, as the Veteran is not shown to possess medical expertise.  See Jandreau, supra.

The medical studies submitted by the Veteran regarding a possible connection between IBS and his service-connected disabilities have been considered; however, the Board finds that such evidence is of a general nature and it does not discuss the specific facts of the Veteran s case; therefore, it is of limited probative value and is outweighed by the VA examiner s negative nexus opinions discussed above.  See Wallin, 11 Vet. App. at 514; see also Sacks, 11 Vet. App. at 317.  Additionally, the VA examiner stated that the isolated studies submitted by the Veteran are outweighed by a review of Up To Date, which is presently accepted medical literature based upon multiple medical studies.

In conclusion, the Board finds that the preponderance of the evidence is against the Veteran s claim of entitlement to service connection for IBS, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.  As such, there is no reasonable doubt to be resolved, and the claim must be denied.  38 U.S.C. � 5107(b); 38 C.F.R. � 3.102; Gilbert, supra.

9. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected posttraumatic stress disorder (PTSD), shell fragment wounds(SFWs), or medication taken for service-connected disabilities

The Veteran claims entitlement to service connection for GERD, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.

Service treatment records do not document complaints, treatment, or diagnosis of GERD.  A November 1965 enlistment examination and a November 1967 separation examination each document normal clinical evaluations of the gastrointestinal system, without noted defects or diagnoses.

Upon VA examination in May 2010, the Veteran reported onset of GERD symptoms five to ten years before, after which he was placed on medication, which helped the condition.  The VA examination noted that the Veteran s GERD did not have onset during active service by his own history; therefore, it was not directly related to active service.  The examiner further opined that there was no relationship between the Veteran s GERD and his PTSD, as GERD was typically caused by sphincter tone abnormality, which was not caused by PTSD.  Additionally, the examiner stated that the Veteran s GERD was not due to or aggravated by medication for his PTSD; by the Veteran s own history, he was placed on Prazosin a year before for PTSD, but he denied aggravation of his GERD as a result.  The examiner noted that the Veteran was on blood pressure medications, which sometimes can aggravate the reflux; however, as discussed above, the Veteran is not service-connected for hypertension.  In sum, the examiner concluded that the Veteran s GERD was not directly due to active service or secondary to service-connected disability or related medication.

Upon VA examination in June 2012, the same VA examiner noted based upon a review of the claims file that the injuries suffered by the Veteran during active service would not have caused his reflux from an anatomical standpoint.  Additionally, the examiner noted that treatment of the Veteran s present service-connected conditions occurred long after the onset of GERD and therefore, these could not be related to GERD since there would be no direct cause and effect.  The examiner concluded that his opinion was unchanged from the prior VA examination regarding GERD to his service-connected conditions.  Moreover, he noted that the Veteran denied aggravation over the years, but noted that medications had helped his conditions.  As such, the examiner concluded again that it was less likely than not that GERD caused by any service-connected disabilities or treatment of such disabilities.

In June 2016, a VA examiner again opined that the Veteran s GERD was less likely than not proximately due to or the result of the Veteran s service-connected conditions, as the etiology of GERD involved relaxation of esophageal sphincter and very common in the general population for all age groups.  Additionally, a review of medical literature in  Up To Date  listed many conditions that increased sympathetic GERD; however, it did not list PTSD.  Additionally, the examiner noted that the studies submitted by the Veteran were isolated studies, while the presently accepted literature in Up To Date would be the more accepted evidence regarding his claims as it is based on multiple medical studies as opposed to isolated studies.  In sum, the examiner noted that his opinions remained unchanged from his prior 2010 and 2012 opinions.

The Board notes that the May 2010, June 2012, and June 2016 VA opinions are of greatest probative value in the context of the Veteran s claim, as the opinions properly considered the Veteran s medical history, the submitted medical literature, and included a reasoned rationale.  See Nieves-Rodriguez, supra.  Significantly, there are no objective medical opinions to weigh against the negative nexus opinions.  Indeed, there is no probative medical evidence of record, which documents a nexus between the Veteran s claimed GERD and his active service, to include service-connected PTSD, SFWs, or medication taken for service-connected disabilities.

The Veteran s lay statements of record are probative evidence insofar as they report observable symptomatology, see Layno, supra; however, to the extent that the Veteran asserts a nexus between GERD and his active service, to include as secondary to a service-connected disability or related treatment, they are afforded less probative value, as the Veteran is not shown to possess medical expertise.  See Jandreau, supra.

The medical studies submitted by the Veteran regarding a possible connection between GERD and his service-connected disabilities have been considered; however, the Board finds that such evidence is of a general nature and it does not discuss the specific facts of the Veteran s case; therefore, it is of limited probative value and is outweighed by the VA examiner s negative nexus opinions discussed above.  See Wallin, 11 Vet. App. at 514; see also Sacks, 11 Vet. App. at 317.  Additionally, the VA examiner stated that the isolated studies submitted by the Veteran are outweighed by a review of Up To Date, which is presently accepted medical literature based upon multiple medical studies.

In conclusion, the Board finds that the preponderance of the evidence is against the Veteran s claim of entitlement to service connection for GERD, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.  As such, there is no reasonable doubt to be resolved, and the claim must be denied.  38 U.S.C. � 5107(b); 38 C.F.R. � 3.102; Gilbert, supra.

10. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities

Finally, the Veteran claims entitlement to service connection for ED, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.

Service treatment records do not document complaints, treatment, or diagnosis of ED.  A November 1965 enlistment examination and a November 1967 separation examination each document normal clinical evaluations, without noted defects or diagnoses.

Upon VA examination in May 2010, the Veteran reported onset of ED in his late 40s.  The examiner noted that the Veteran s complaints of ED were noted in 2003, when he was placed upon prescription medication.  Ultimately, the examiner concluded that the Veteran s diagnosed ED was not attributable to his PTSD, as PTSD by itself does not cause ED.  Additionally, the examiner noted there was no documented onset of ED during active service.  The examiner also noted that the Veteran was not on any PTSD medication at the time his ED had onset; therefore, no secondary cause could be attributed to PTSD or related medication.  Rather, the examiner concluded that it was more likely that the Veteran s ED was related to his longstanding hypertension.

In June 2016, a VA examiner opined that the Veteran s ED was less likely than not proximately due to or the result of a service-connected condition.  The examiner noted that the cause of ED was vascular; additionally, the Veteran had a history of hypertension with related medication treatment, which would be the more likely etiologies since these are very causative or primary for ED.  The examiner stated that it would be purely speculative to opine regarding secondary causation or aggravation by PTSD since the onset of ED several years following discharge from active service would be evidence against such a cause and effect.  Additionally, the examiner noted that the studies submitted by the Veteran in support of his claim are isolated studies, while a review of presently accepted literature (Up To Date) would be the accepted evidence regarding his claims as it is based on multiple medical studies as opposed to isolated studies presented by Veteran.

An additional June 2016 treatment note documents that the Veteran s ED claim was reviewed with the VA head staff urologist, who concurred with the prior VA examiner s negative nexus opinion, as he was unaware of any confirmed and repeated medical studies that demonstrated ED occurring many years following onset of PTSD.  Rather, he noted that the direct cause of ED by PTSD is usually a short time following the onset of condition.  At this is not the case with the Veteran, it is therefore less likely than not that his ED is related to PTSD.

The Board acknowledges that a December 2017 appellant brief asserts that the negative nexus opinions rendered by VA examiner s ignored VA s own medical literature identifying a link between PTSD and ED, especially when  considering that the Veteran s mental health condition and ED were diagnosed within a month of each other, it is reasonable to assume that they are linked, particularly when considered in light of the research.   However, the Board affords the greatest probative value to the VA opinions of record, as the opinions properly considered the Veteran s medical history, the submitted medical literature, and included a reasoned rationale, which linked the Veteran s ED to his longstanding hypertension.  See Nieves-Rodriguez, supra.

The Veteran s lay statements of record are probative evidence insofar as they report observable symptomatology, see Layno, supra; however, to the extent that the Veteran asserts a nexus between ED and his active service, to include as secondary to a service-connected disability or related treatment, they are afforded less probative value, as the Veteran is not shown to possess medical expertise.  See Jandreau, supra.

The medical studies submitted by the Veteran regarding a possible connection between ED and his service-connected disabilities have been considered; however, the Board finds that such evidence is of a general nature and it does not discuss the specific facts of the Veteran s case; therefore, it is of limited probative value and is outweighed by the VA examiner s negative nexus opinions discussed above.  See Wallin, 11 Vet. App. at 514; see also Sacks, 11 Vet. App. at 317.  Additionally, the VA examiner noted that the isolated studies submitted by the Veteran are outweighed by a review of Up To Date, which is presently accepted medical literature based upon multiple medical studies.

In conclusion, the Board finds that the preponderance of the evidence is against the Veteran s claim of entitlement to service connection for ED, to include as secondary to service-connected PTSD, SFWs, or medication taken for service-connected disabilities.  As such, there is no reasonable doubt to be resolved, and the claim must be denied.  38 U.S.C. � 5107(b); 38 C.F.R. � 3.102; Gilbert, supra.

Increased Ratings

Disability ratings are determined by applying the criteria set forth in the VA s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity.  Individual disabilities are assigned separate diagnostic codes.  38 U.S.C. � 1155 (2012); 38 C.F.R. � 4.1 (2017).  The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment.  38 C.F.R. � 4.10 (2017).

In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran s disability.  38 C.F.R. � 4.1, 4.2 (2017); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991).  If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned.  38 C.F.R. � 4.7 (2017).  When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant.  38 C.F.R. � 4.3 (2017).  In every instance where the schedule does not provide a compensable evaluation, a noncompensable evaluation will be assigned when the requirements for a compensable evaluation are not met.  38 C.F.R. � 4.31 (2017).

The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided.  38 C.F.R. � 4.14 (2017).  Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition.  Id.

Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance.  It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements.  The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion.  Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled.  A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like.  38 C.F.R. � 4.40 (2017).

Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use.  DeLuca v. Brown, 8 Vet. App. 202 (1995).  The provisions regarding the avoidance of pyramiding, see 38 C.F.R. � 4.14, do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups.  However, those provisions should only be considered in conjunction with the diagnostic codes predicated on limitation of motion.  38 C.F.R. �� 4.40, 4.45 (2017).

The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability.  Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint.  38 C.F.R. � 4.59 (2017).  However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable diagnostic code.  Mitchell v. Shinseki, 25 Vet. App. 32 (2011).

When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran s capacity for adjustment during periods of remission.  The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner s assessment of the level of disability at the moment of the examination.  38 C.F.R. � 4.126(a) (2017).  When evaluating the level of disability from a mental disorder, VA also will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment.  38 C.F.R. � 4.126(b).

Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as  staged  ratings.  See Hart v. Mansfield, 21 Vet. App. 505 (2007).  For the Veteran s increased rating claims discussed herein, the Board has considered the relevant appeal periods, as well as whether any additional staged rating periods are warranted.

11. Entitlement to an increased disability rating in excess of 20 percent for residuals of a shell fragment wound, muscle group II, left shoulder, with retained foreign body

The Veteran s service-connected residuals of a shell fragment wound, muscle group II, left shoulder, with retained foreign body, is currently rated as 20 percent disabling under DC 5302, regarding injury to muscle group II, from December 4, 1968.  38 C.F.R. � 4.73, DC 5302 (2017).

Thereunder, a 20 percent disability rating is warranted for moderate or moderately severe functional impairment of group II muscles on the non-dominant side, while a maximum schedular 30 percent disability rating is warranted for severe functional impairment of group II muscles on the non-dominant side.  Id.

Evaluation of muscle injuries as moderate, moderately severe, or severe, is based on the type of injury, the history and complaints of the injury, and objective findings.  38 C.F.R. � 4.56 (2017).  A moderate disability is characterized by the following:  a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection; history and complaint of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles; and objective findings of entrance and exit scars, small or linear, indicating short track of missile through muscle tissue; and some loss of power or lowered threshold of fatigue when compared to the sound side.  Id.

A moderately severe disability of the muscles is characterized by the following:  evidence of a through and through or deep penetrating wound by a high velocity missile of small size or a large missile of low velocity, with debridement or with prolonged infection, or with sloughing of soft parts, or intermuscular scarring; service department records or other sufficient evidence showing hospitalization for a prolonged period in service for treatment of a wound of severe grade; records of consistent complaints of cardinal symptoms of muscle wounds; evidence of unemployability due to an inability to keep up with work requirements; objective findings including relatively large entrance and (if present) exit scars so situated as to indicate the track of a missile through important muscle groups; indications on palpation of moderate loss of deep fascia, or moderate loss of muscle substance or moderate loss of normal firm resistance of muscles compared with the sound side; and tests of strength and endurance of the muscle groups involved.  Id.

A severe muscle injury is a through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring, where there was hospitalization for a prolonged period for treatment of the wound.  Id.  There should be a record of consistent complaint of cardinal signs and symptoms of muscle disability, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements.  Id.  Severe disability of the muscles requires ragged, depressed and adherent scars, loss of deep fascia or muscle substance or soft flabby muscles in the wound area, and severe impairment on tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side.  Id.  If present, the following are also signs of severe muscle disability: (a) x-ray evidence of minute multiple scattered foreign bodies; (b) adhesion of the scar; (c) diminished muscle excitability on electrodiagnostic tests; (d) visible or measurable atrophy; (e) adaptive contraction of an opposing group of muscles; (f) atrophy of muscle groups not in the track of the missile; or (g) induration or atrophy of an entire muscle following simple piercing by a projectile.  Id.

Following a review of the evidence of record, the Board finds that the preponderance of evidence weighs against the Veteran s claim of entitlement to an increased disability rating in excess of 20 percent for residuals of a shell fragment wound, muscle group II, left shoulder, with retained foreign body for the entire period on appeal, as the probative evidence of record does not document severe functional impairment of group II muscles of the Veteran s non-dominant left shoulder for any period on appeal.

Upon VA examination in July 2010, the Veteran reported increasing left shoulder pain while working as an electrician; he stated that he could do almost anything but experienced aching left shoulder pain after pulling or reaching overhead.  Physical examination revealed left shoulder flexion and abduction to 120 degrees, external rotation to 60 degrees, and internal rotation to 80 degrees, without any additional loss of range of motion upon repetition due to pain or weakness.

Upon recent VA examination in May 2017, the examiner reported near-constant pain in his left shoulder after a fall onto his left shoulder one week before.  The Veteran reported left shoulder pain with flare ups after exertion.  Upon range of motion testing, the Veteran displayed left shoulder flexion and abduction to 45 degrees, and external and internal rotation to 70 degrees.  The examiner noted that the Veteran s diminished left shoulder range of motion did not represent his chronic disability, but was a result of a recent acute injury to his left shoulder.  Similarly, the Veteran s decreased muscle strength of Group II shoulder muscles was not due entirely to the Veteran s service-connected left shoulder disability, but also to his recent injury to the shoulder.  The examiner noted there was no effect on muscle substance or function weakness (Group II), lowered threshold of fatigue (Group II), fatigue-pain (Group II), and no left shoulder atrophy or ankylosis; rotator cuff conditions; shoulder instability; clavicle, scapula, acromioclavicular (AC) joint or sternoclavicular joint conditions; or impairment of the humerus.  The examiner concluded that the Veteran s left shoulder disability would limit his ability to work over his head.

Significantly, the evidence of record, including as discussed above, does not document that the Veteran s residuals of a shell fragment wound, muscle group II, left shoulder, with retained foreign body has resulted in severe functional impairment of group II muscles of the Veteran s non-dominant left shoulder for any period on appeal.  See 38 C.F.R. � 4.73, DC 5302.

The Board has also considered whether an increased disability rating is warranted under an alternate diagnostic code regarding disability of the shoulder; however, the objective medical evidence does not show any nonunion of the left clavicle or scapula, malunion of the left humerus or recurrent dislocation at the left scapulohumeral joint, or ankylosis of the left scapulohumeral articulation.  As such, the application of DCs 5200, 5202, or 5203 do not warrant an increased disability rating for any period on appeal.  See 38 C.F.R. � 4.71a, DCs 5200-03 (2017).

The Board also considered the applicability of a higher rating based on functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. �� 4.40, 4.45, and 4.59.  See DeLuca v. Brown, 8 Vet. App. 202 (1995), Burton v. Shinseki, 25 Vet. App. 1 (2011).  However, the Board finds that the Veteran s reported left shoulder functional impairment is considered by the currently assigned disability rating under DC 5302.  The Board has also considered the Veteran s ongoing reports of painful motion in his left shoulder; however, such pain is appropriately contemplated by his currently assigned compensable disability rating.  Mitchell, 25 Vet. App. 32 (2011).

In sum, the preponderance of evidence weighs against the Veteran s claim of entitlement to an increased disability rating in excess of 20 percent for residuals of a shell fragment wound, muscle group II, left shoulder, with retained foreign body for the entire period on appeal.  As the preponderance of evidence is against the claim, there is no reasonable doubt to be resolved, and the claim must be denied.  See 38 U.S.C. � 5107(b); 38 C.F.R. �� 3.102, 4.3 (2017); Gilbert, supra.

12. Entitlement to an increased disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to September 7, 2011, and in excess of 50 percent thereafter

The Veteran s service-connected PTSD is currently rated as 30 percent disabling prior to September 7, 2011 and as 50 percent disabling thereafter, under Diagnostic Code (DC) 9411 of the General Rating Formula for Mental Disorders.  See 38 C.F.R. � 4.130, DC 9411 (2017).

Under the applicable rating criteria, a 30 percent disability rating is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to symptoms such as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events).  Id.

A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  Id.

A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships.  Id.

Finally, a 100 percent disability rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name.  Id.

When determining the appropriate disability evaluation to assign, the Board s primary consideration is a Veteran s symptoms, but it must also make findings as to how those symptoms impact a Veteran s occupational and social impairment.  Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013).  The use of the term  such as  in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating.  Mauerhan v. Principi, 16 Vet. App. 436 (2002).  Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating.  Id. at 442.  Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran s impairment must be  due to  those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.  Vazquez-Claudio, 713 F.3d at 118.

Turning to the evidence of record, a July 2009 Vet Center letter reports that the Veteran had been a patient at the Vet Center since September 2003.  He reported struggles with social isolation and avoidance, which resulted in his intermittent attendance at group sessions.  The counselor noted the Veteran had attended regularly since February 2009, and he had reported bouts of irritability and anger outbursts, which affected his relationships at home, with family, and the public.

Upon VA examination in May 2010, the Veteran reported PTSD symptoms including irritability, anger, sleep impairment with nightmares, hyperarousal, and lack of energy.  He stated that he currently lived with his wife and had good relationships with his brothers and with people in the community as he volunteered to cut the grass at a local cemetery.  He stated that he had not worked since December 2001 due to his physical disabilities, which he associated with sleep impairment due to pain.  Upon mental status examination, he appeared clean and well-groomed, with normal speech, mood, and affect.  Thought processes were logical, without delusions or hallucinations.  Judgement and insight were intact, without any suicidal or homicidal ideation, though he reported passive suicidal ideation a year before.  The examiner concluded that the Veteran s PTSD resulted in sleep impairment, without any thought impairment or communication issues, and occupational impairment due to physical disability with resulting pain.

Upon VA PTSD examination in July 2010, the examiner noted that his first wife died from a heart attack after thirty-five years of marriage, but that he had been married to his second wife for 3 years and that they got along fairly well.  He reported that he stopped working in 2001 as a master electrician due to a cervical spine condition, and that he currently spent time working in his shop, mowing the yard, or visiting with his brothers.  Upon mental status examination, he appeared alert, oriented, and well-groomed.  His speech, thoughts, and memory were normal, without delusions or hallucinations.  His insight and judgment were adequate, and he denied suicidal or homicidal ideation.  The examiner concluded that the Veteran s symptoms were mild, and that his PTSD did not preclude or negative impact employment.

An April 2012 Vet Center letter from the Veteran s counselor reported that the Veteran had been seen since September 2003, with past suicidal and homicidal ideation, and symptoms of irritability, inflexibility, and intrusive thoughts with lack of concentration.  He was noted to have problems understanding simple concepts due to anxiety and stereotypical language or circumlocutory speech, with social isolation and continuous depression, which interferes with his routine activities and hinders his ability to function independently and appropriately without the help of his wife.  The counselor reported that the Veteran had not been able to work since 2003 due to increased severity of his PTSD because of his inability to deal with other people without having frequent conflict and anger outbursts, as well as physical inability do the work of an electrician due to physical disability.  The counselor opined that the Veteran was not employable at this time due to his PTSD and other service-connected disabilities.

The Veteran was most recently afforded a VA PTSD examination in June 2017.  At that time, he reported PTSD symptoms including depressed mood, anxiety, and chronic sleep impairment.  Upon mental status examination, he appeared alert and oriented, with adequate grooming and hygiene, and no obvious cognitive problems.  His speech was fluent and thought processes were logical.  The examiner concluded that the Veteran s PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation functional impact.  The examiner noted that the Veteran generally got along with others, although he could be argumentative, and that his sleep disturbance, hyper vigilance, and exaggerated startle reflex would likely impair occupational functioning in stressful situations; however, he concluded that the Veteran would likely be able to perform job duties satisfactorily under normal conditions.

Following a review of the evidence of record, including as discussed above, the Board finds that the preponderance of the evidence weighs against the Veteran s claim of entitlement to an increased disability rating in excess of 30 percent prior to September 7, 2011 and in excess of 50 percent thereafter.

In order to warrant an increased 50 percent disability rating prior to September 7, 2011, the Veteran s overall impairment from his PTSD would need to approximate occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  See 38 C.F.R. � 4.130, DC 9411.  Notably, however, upon VA examination in May 2010, the examiner concluded that the Veteran s PTSD resulted in sleep impairment, without any thought impairment or communication issues, and occupational impairment due to physical disability with resulting pain.  In July 2010, the Veteran s PTSD symptoms were categorized as mild with no negative impact employment.  The Board concludes that such symptomatology does not more closely approximate occupational and social impairment with reduced reliability and productivity prior to September 7, 2011; nor are such symptoms of similar severity, frequency, and duration as those associated with a 50 percent disability rating.  Id.

As the Veteran s symptoms do not meet the rating criteria for a higher 50 percent disability rating prior to September 7, 2011, it follows that his symptoms also do not meet the more severe rating criteria for an increased 70 or 100 percent disability rating.  Significantly, he has not shown the required severity of occupational and social impairment necessary for an increased 70 or 100 percent disability rating during the rating period, and his symptoms as a whole are not of similar severity, frequency, and duration as those particular symptoms associated with a 70 or 100 percent disability rating.  Vazquez-Claudio, supra

Similarly, in order to warrant an increased 70 percent disability rating from September 7, 2011, the Veteran s overall impairment from his PTSD would need to approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals, which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships.  See 38 C.F.R. � 4.130, DC 9411.  Notably, however, upon VA examination in June 2017, the examiner concluded that the Veteran s PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation functional impact.  The examiner noted that the Veteran generally got along with others, although he could be argumentative at times, and that his sleep disturbance, hyper vigilance, and exaggerated startle reflex would likely impair occupational functioning in stressful situations; however, he concluded that the Veteran would likely be able to perform job duties satisfactorily under normal conditions.  The Board concludes that such symptomatology does not more closely approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood from September 7, 2011; nor are such symptoms of similar severity, frequency, and duration as those associated with a 70 percent disability rating.  Id.

To the extent that an April 2012 Vet Center letter from the Veteran s counselor reported that the Veteran had experienced more severe symptoms, which could potentially support the assignment of an increased 70 percent disability rating, the Board notes that such findings are inconsistent with the additional evidence of record, including the June 2017 VA examination.  As such, the April 2012 Vet Center letter is of less probative value regarding the severity of the Veteran s PTSD.  Rather, the Board affords more probative value to the June 2017 VA examination discussed above, which was based upon the Veteran s reported history and objective psychiatric testing, and allows for application of the rating criteria.

As the Veteran s symptoms do not meet the rating criteria for a higher 70 percent disability rating, it follows that his symptoms also do not meet the more severe rating criteria for an increased 100 percent disability rating.  Significantly, he has not shown the required severity of occupational and social impairment necessary for an increased 70 or 100 percent disability rating during the rating period, and his symptoms as a whole are not of similar severity, frequency, and duration as those particular symptoms associated with a 70 or 100 percent disability rating.  Vazquez-Claudio, supra

Thus, the Board finds that the preponderance of the evidence weighs against the Veteran s claim of entitlement to an increased disability rating in excess of 30 percent prior to September 7, 2011 and in excess of 50 percent thereafter.  As the preponderance of the evidence is against the Veteran s claim, there is no reasonable doubt to be resolved, and the claim must be denied.  38 U.S.C. � 5107(b); 38 C.F.R. �� 3.102, 4.3; Gilbert, supra.

REMANDED ISSUES

Entitlement to an effective date prior to September 7, 2011 for the grant of a total disability rating based on individual unemployability (TDIU) is remanded.

Entitlement to an effective date prior to September 7, 2011 for the grant of Dependents' Education Assistance (DEA) benefits is remanded.

1. Entitlement to an effective date prior to September 7, 2011 for the grant of a total disability rating based on individual unemployability (TDIU)

The law provides that a TDIU may be granted upon a showing that the veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities.  See 38 U.S.C. � 1155 (2012); 38 C.F.R. �� 3.340, 3.341, 4.16 (2017).  Consideration may be given to a Veteran s level of education, special training, and previous work experience in arriving at a conclusion, but not to his or his age or the impairment caused by non-service-connected disabilities.  See 38 C.F.R. �� 3.341, 4.16, 4.19 (2017).

The United States Court of Appeals for Veterans Claims (CAVC) has indicated that the unemployability question, or the veteran s ability or inability to engage in substantial gainful activity, has to be looked at in a practical manner and that the crux of the matter rests upon whether a particular job is realistically within the capabilities, both physical and mental, of the appellant.  See Moore v. Derwinski, 1 Vet. App. 356 (1991).  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).

To qualify for a total rating for compensation purposes, the evidence must show (1) a single disability rated as 100 percent disabling; or (2) that the disabled person is unable to secure or follow a substantially gainful occupation as a result of his or his service-connected disabilities, with one disability ratable at 60 percent or more, or, for more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent or more.  38 C.F.R. � 4.16(a).

Veterans who are unable to secure gainful employment by reason of service-connected disabilities, but fail to meet the percentage criteria in 38 C.F.R. � 4.16(a), may receive extraschedular consideration.  See 38 C.F.R. � 4.16(b).  Specifically, rating boards should submit to the Director of Compensation Service for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in 38 C.F.R. � 4.16(a).  Id.  The rating board will include a full statement as the veteran s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue.  Id.

The Veteran is currently service-connected for PTSD (rated as 30 percent disabling from October 1, 2002 and as 50 percent disabling from September 7, 2011), residuals of SFW, muscle group II, left shoulder (rated as 20 percent disabling from December 4, 1968), left shoulder scar (rated as 10 percent disabling from May 6, 1999), residuals of SFW, left hip (rated as 10 percent disabling from November 28, 2001), tinnitus (rated as 10 percent disabling from July 29, 2008), residuals of SFW, muscle group VI, left shoulder (rated as 10 percent disabling from May 23, 2017), residuals of SFW, left forearm, left wrist, left leg, and right forearm (each rated as noncompensable, or 0 percent disabling, from December 4, 1968, residuals of SFW, left ankle (rated as noncompensable from August 15, 1989), and right shoulder strain (rated as noncompensable from August 10, 2007.

Thus, the Veteran s combined disability rating is 20 percent from December 4, 1968, 30 percent from May 6, 1999, 40 percent from November 28, 2001, 60 percent from October 1, 2002, and 70 percent from September 7, 2011.  As such, he meets the threshold criteria for consideration of a TDIU rating from September 7, 2011, but no sooner.  See 38 C.F.R. � 4.16(a).  Notably, however, failure to meet the schedular percentage requirements does not preclude the availability of a TDIU rating on an extraschedular basis under 38 C.F.R. � 4.16(b).

Additionally, the Board is mindful that the Veteran has consistently reported that he last worked as a master electrician in December 2001, at which time he had to stop working due to pain and resulting functional impairment from his service-connected disabilities.  This is consistent with an August 2002 private treatment record, which documents a physician s opinion that the Veteran was unable to continue to work due to pain from his various disabilities, as well as a July 2003 Social Security Administration (SSA) determination and transmittal, which documents that the Veteran was found to be disabled by SSA from December 31, 2001 due to primary osteoarthritis and secondary disorders of the back.

As such evidence suggests that the Veteran was unemployable due to his service-connected disabilities prior to September 7, 2011, especially in light of his prior work experience as an electrician, remand of the Veteran s claim of entitlement to TDIU rating prior to September 7, 2011 is warranted for referral to the Director of Compensation Service for extraschedular consideration.  See 38 C.F.R. � 4.16(b).  The Board cannot assign an extraschedular rating in the first instance.  See Floyd v. Brown, 9 Vet. App. 88 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996).  If, and only if, the Director determines that an extraschedular evaluation is not warranted, does the Board then have jurisdiction to decide the extraschedular TDIU claim on the merits.  See Anderson v. Shinseki, 22 Vet. App. 423 (2009).

2. Entitlement to an effective date prior to September 7, 2011 for the grant of Dependents  Education Assistance (DEA) benefits

The Veteran also claims entitlement to an effective date prior to May 6, 2008 for the grant of eligibility for Dependents  Educational Assistance (DEA) benefits under 38 U.S.C. � 3500 et seq., based upon his argument, discussed above, that he is entitled to an effective date earlier for the grant of a TDIU rating.

The Veteran s claim of entitlement to an effective date prior to September 7, 2011 for the grant of eligibility for Dependents  Educational Assistance (DEA) benefits under 38 U.S.C. � 3500 et seq., remains inextricably intertwined with his claim of entitlement to entitlement to an effective date prior to September 7, 2011 for the grant of a TDIU rating; therefore, remand of this claim is also warranted.  See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991).

The matters are REMANDED for the following action:

Refer the Veteran s claim of entitlement to a TDIU rating prior to September 7, 2011 to the Director of Compensation Service for consideration of TDIU on an extraschedular basis.  Include a full statement as to the Veteran s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue.  See 38 C.F.R. � 4.16(b).

A. P. SIMPSON

Veterans Law Judge

Board of Veterans  Appeals

ATTORNEY FOR THE BOARD	D. Chad Johnson, Counsel