LUMBOSACRAL OR CERVICAL STRAIN

TIMOTHY COTHREL · 2026 · Case ID: A26027449

MIXED

Summary

The veteran, who served in the U.S. Navy from November 1967 to February 1969, appeals the denial of service connection for right shoulder strain, chronic kidney disease, elevated liver enzymes, and allergic rhinitis, while seeking service connection for left knee degenerative arthritis and gout. The Board granted service connection for left knee degenerative arthritis, finding the veteran's statement of in-service injury and post-service symptoms sufficient to establish continuity of symptomatology, despite the absence of specific notations in service treatment records. Service connection for gout was also granted, with the Board finding the veteran's recollection of a 1960s diagnosis, coupled with the TERA memorandum's concession of potential links between in-service exposures and symptoms, raised an approximate balance of evidence favoring service connection. The Board denied service connection for right shoulder strain, finding the evidence weighed against an in-service cause and that the examiner's opinion, noting the delay in seeking treatment and the nature of strains, was more probative. Chronic kidney disease and elevated liver enzymes were denied due to lack of in-service incurrence and, for liver enzymes, the absence of a diagnosed disability impacting earning capacity. Allergic rhinitis was denied, with the Board finding clear and unmistakable evidence that the condition pre-dated service and was not aggravated by service or toxic exposures. The Board also granted entitlement to Total Disability based on Individual Unemployability (TDIU), finding the cumulative impact of the veteran's service-connected disabilities rendered him unemployable.

Rationale

STRs and separation exam silent for shoulder disability; First treatment sought decades after service; VA examiner noted acute nature of strains and lack of chronic symptoms

Service Branch

NAVY

Special Benefit

TDIU

Docket No.

250626-556247

Full Decision Text

Citation Nr: A26027449
Decision Date: 03/26/26 Archive Date: 03/26/26

DOCKET NO. 250626-556247
DATE: March 26, 2026

ORDER

Entitlement to service connection for right shoulder strain is denied.

Entitlement to service connection for left knee degenerative arthritis is granted.

Entitlement to service connection for chronic kidney disease is denied.

Entitlement to service connection for elevated liver enzymes is denied.

Entitlement to service connection for allergic rhinitis is denied.

Entitlement to service connection for gout is granted.

Entitlement to a total disability for individual unemployability is granted.

FINDINGS OF FACT

1. The evidence persuasively weighs against finding that the Veteran's right shoulder strain began during service or is otherwise related to service.

2. The Veteran noted injuries to his left knee during service.

3. The Veteran experienced persistent symptoms of a left knee injury after service.

4. The Veteran has a diagnosis of arthritis of the left knee.

5. The evidence persuasively weighs against finding the Veteran's chronic kidney disease began during service or is otherwise related to service, to include toxic exposures during service.

6. Abnormal liver enzymes are not a disability for which service connection can be established under VA regulations.

7. The Veteran's allergic rhinitis, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by service and was not otherwise caused by toxic exposures during service.

8. The Veteran's gout began during service.

9. The synergistic impairment caused by the Veteran's combined service-connected disabilities renders him unable to perform the physical or mental tasks necessary to secure and maintain a gainful occupation.

CONCLUSIONS OF LAW

1. The criteria for service connection for right shoulder strain are not met. 38 U.S.C. §§ 1110, 5107;?38 C.F.R. §§ 3.102, 3.303.?

2. The criteria for service connection for left knee arthritis are met. 38 U.S.C. §§ 1110, 5107;?38 C.F.R. §§ 3.102, 3.303.?

3. The criteria for service connection for chronic kidney disease are not met. 38 U.S.C. §§ 1110, 5107;?38 C.F.R. §§ 3.102, 3.303.?

4. The criteria for service connection for elevated liver enzymes are not met. 38 U.S.C. §§ 1110, 5107;?38 C.F.R. §§ 3.102, 3.303.?

5. The criteria for service connection for allergic rhinitis are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306.

6. The criteria for service connection for gout are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

7. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 3.340, 4.16.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the U.S. Navy from November 1967 until his honorable discharge in February 1969. The Board recognizes his service to our country, and the sacrifices it entailed.

This matter is before the?Board of Veterans' Appeals?(Board) from rating decisions of June 2025 (rhinitis), April 10, 2025 (left knee, right shoulder, gout) and April 2, 2025 (kidney disease, elevated liver enzymes) from the Department of Veterans Affairs (VA) Regional Office (RO), which is also the agency of original jurisdiction (AOJ).

The April 10, 2025 decision was a Higher Level Review of a March 2025 rating decision and reviewed only the evidence at the time of that decision.

On the June 2025 Notice of Disagreement (NOD or VA Form 10182), the Veteran elected Hearing Review. A September 2025 notification advised the Veteran that a hearing was scheduled for October 21, 2025. The Veteran did not appear for the scheduled Board hearing.

The April 10, 2025 decision was a Higher Level Review of a March 2025 rating decision and reviewed only the evidence at the time of that decision.

Therefore, the Board may consider only the evidence of record at the time of the June 2025 rating decision (rhinitis), March 2025 rating decision (left knee, right shoulder, gout) and April 2, 2025 rating decision (kidney disease, elevated liver enzymes), as well as any evidence submitted within 90 days after the scheduled hearing. 38?C.F.R. §?20.302(c).

Notably, the Veteran filed a supplemental claim in December 2025 that addressed the rhinitis, gout, and kidney disease disabilities. Because the appeal of those issue was pending, the AOJ should have rejected the Veteran's claim based on the prohibition against concurrent election of review options-i.e., once a veteran chooses a particular review option, they cannot pursue another one so long as the first one is still pending. See 38 U.S.C. § 5104C(a)(2); 38 C.F.R. § 3.2500(b). The AOJ nevertheless adjudicated those issues and rendered a new rating decision. Because the AOJ denied service connection for all three disabilities, the error is moot. What is not moot is the submission of evidence in support of that supplemental claim after the rating decision on appeal.

As explained above, the Board typically could not consider evidence submitted after the rating decision to support a supplemental claim, but here, because the Veteran selected the hearing docket, he was afforded 90 days after the scheduled hearing date to submit documentary evidence. Thus, all evidence submitted by the Veteran between October 21, 2025 and January 20, 2026, may be considered by the Board in this decision.

If the Veteran would like the VA to consider any additional evidence, the Veteran may file another supplemental claim and submit or identify such evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Additionally, the Board notes that the Veteran identified four issues on his NOD that the Board had already adjudicated in a May 2025 decision: cholesterol, benign prostatic hyperplasia, anemia and erectile dysfunction. A decision by the Board cannot be appealed to the Board, and the Board will not readjudicate issues in a previous Board decision unless they are the subject of a motion or order that nullifies the previous Board decision. 38 U.S.C. § 7104.

This appeal has been advanced on the Board's docket. 38 C.F.R. § 20.900 (c). The Board interprets the advance on docket status of this case as an intent to have this matter reviewed in an expeditious manner, which the Board finds to be an implicit waiver of any right to change Board dockets under Williams v. McDonough, 37?Vet. App.?305 (2024).

Service Connection Background

Service connection can be established by showing the claimed disability manifested while the Veteran was in service. 38 C.F.R. § 3.303(a). See also, Flynn v. Brown, 6 Vet. App. 500, 503 (1994) (noting "the element of cause and effect has been totally by-passed in favor of a simple temporal relationship between the incurrence of the disability and the period of active duty").

If the claimed disability did not manifest until after service, direct service connection is established by showing the disability was incurred in service. 38 C.F.R. § 3.303(d). Showing in-service incurrence generally boils down to establishing three essential elements: (1) the claimed disability exists; (2) an in-service injury, disease, or event occurred; and (3) there was a causal relationship, or nexus, between the first two elements. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may also be presumed to be related to service for certain chronic disabilities if they manifested within certain time limits after
was incurred in service. 38 C.F.R. § 3.303(d). Showing in-service incurrence generally boils down to establishing three essential elements: (1) the claimed disability exists; (2) an in-service injury, disease, or event occurred; and (3) there was a causal relationship, or nexus, between the first two elements. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may also be presumed to be related to service for certain chronic disabilities if they manifested within certain time limits after the veteran's service, or if symptoms associated with a disease or injury were "noted" during service, and those symptoms persisting up to the point of diagnosis of a chronic condition. In this context, a disability is considered "chronic" only if it is expressly identified as such in the governing statutes or regulations. 38 U.S.C. §§ 1101(3), 1112; 38 C.F.R. §§ 3.303(b), 3.307(a), 3.309(a). This is commonly referred to as service connection by continuity and chronicity-the continuity being the persistence of symptoms after service, and the chronicity being the formal diagnosis of a disability listed in 38 C.F.R. § 3.309(a).

When adjudicating appeals, the Board applies an intentionally generous standard of proof unique in American jurisprudence, created in recognition of the nation's great debt to its veterans. Wise v. Shinseki, 26 Vet. App. 517, 531 (2014).

"Reasonable doubt" is raised when the evidence does not "satisfactorily prove or disprove the claim," but there is at least an "approximate balance" of positive and negative evidence. When that balance is achieved, a reasonable doubt is raised, and the veteran receives the benefit of that doubt. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

Thus, when the evidence in favor of the veteran on a given issue is at least nearly equal to the evidence against them, the Board finds in the veteran's favor. See, e.g., Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001).

1. Entitlement to service connection for right shoulder strain is denied.

The Veteran contends his right shoulder strain (and claimed right shoulder arthritis) and left knee degenerative arthritis were caused during service from the use of ladders putting stress on his body, falls from ladders, working on his hands and knees chipping paint and painting, and from the motion of the vessel. June 2025 NOD; April 2022 and October 2022 VA Form 21-4138 Statements.

The Veteran has a current diagnosis of right shoulder strain, as conceded by the AOJ in the March 2025 rating decision. The Veteran's STRs and separation examination are silent for a right shoulder disability. See May 2022 STR.

A January 2025 VA examination noted the Veteran first sought treatment for right shoulder pain in 2009, forty years after service. Records show in 2009, the Veteran was diagnosed with right shoulder muscle tightness, which was treated with physical therapy and resolved four months later. In 2012, the Veteran reported a history of shoulder bursitis that was treated with ibuprofen. In 2015 the Veteran reported he could not resume playing golf due to the shoulder condition. The examiner, in considering whether the bursitis could be traced to service, noted that bursitis is caused by overuse near in time to when the pain occurs and usually resolves with rest.

The current diagnosis of right shoulder strain was made in January 2023. The examiner noted that a strain is due to a tear of a muscle or tendon in the shoulder and is not caused by arthritis or bursitis, and pain occurs near the time of the injury, not years later. As noted above regarding the Veteran's assertion of having gout since the 1960s, the examiner noted that gout is a type of inflammatory arthritis that does not affect the shoulder. In addition, gout attacks are caused by diet, therefore the gout was not caused or aggravated by the Veteran's physical activities during service. The examiner found the records show acute conditions of the right shoulder and no evidence of a chronic shoulder strain during or near in time to service that would have been caused by the Veteran's inservice activities.

Conclusion

The Board has reviewed the medical evidence and finds it consistent with the findings of the VA examinations. The record shows the Veteran
itis, and pain occurs near the time of the injury, not years later. As noted above regarding the Veteran's assertion of having gout since the 1960s, the examiner noted that gout is a type of inflammatory arthritis that does not affect the shoulder. In addition, gout attacks are caused by diet, therefore the gout was not caused or aggravated by the Veteran's physical activities during service. The examiner found the records show acute conditions of the right shoulder and no evidence of a chronic shoulder strain during or near in time to service that would have been caused by the Veteran's inservice activities.

Conclusion

The Board has reviewed the medical evidence and finds it consistent with the findings of the VA examinations. The record shows the Veteran did not incur left knee and right shoulder injuries during service and first sought treatment for these disabilities decades after service.

The only evidence connecting left knee and right shoulder disabilities and service are the Veteran's bare assertions. The Board acknowledges the Veteran's belief that his left knee arthritis and right shoulder strain were caused by the physical demands of service. While the Veteran is competent to report on his symptoms, the causal connection of his symptoms to prior events is medically complex and outside his competence, where the record does not show the Veteran has the medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

The Board finds the VA examiners' opinions to be the most probative evidence regarding causation. The examiners demonstrated an accurate understanding of the Veteran's medical history and provided rationales that explain the conclusions and give insight into the medical aspects of the Veteran's disabilities. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

The Board also considered whether the Veteran is entitled to service connection for his left knee arthritis as a "chronic disease" under 38 C.F.R. § 3.309 (a). Here, the record does not show the Veteran's arthritis was present during or within one year of separation from service with symptoms continuing until its later diagnosis. Therefore, service connection is not warranted on that presumptive basis. See also Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The Board notes that for this same reason, the Veteran's claimed arthritis of the right shoulder, were it determined to be a current disability, would also not meet the criteria for service connection as a chronic disease.

The Board finds the record persuasively weighs against finding that the Veteran's left knee and right shoulder disabilities were incurred in or caused by service and the benefit-of-the-doubt rule does not apply. These appeals are denied.

2. Entitlement to service connection for left knee arthritis is granted.

The Veteran has a current diagnosis of left knee degenerative arthritis, as conceded by the AOJ in the March 2025 rating decision. The Veteran's STRs and separation examination are silent for any notation, treatment or diagnosis of a left knee disability. See May 2022 Service Treatment Record (STR) - Medical. However, the Veteran provided a detailed statement describing in-service injuries to his knees. See October 2022 VA 21-4138 Statement In Support of Claim. Furthermore, during a January 2023 VA medical examination, the Veteran reported being diagnosed with "gouty arthritis" since the 1960s. See January 2023 C&P Exam.

The Board concurs with VA examiners in January 2023 and 2025 who disregarded this purported diagnosis, which was unsupported by any independent, objective evidence because the Veteran is not qualified to self-diagnose a complex knee condition. He is, however, fully qualified to perceive, remember, and report symptoms of a complex knee condition. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (a lay person is competent to testify as to "observable symptomatology"); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (competence of evidence is a question of fact to be addressed by the Board).

In establishing service connection by continuity and chronicity, it is the identification of symptoms that matters. See, e.g., Fountain v. McDonald, 27 Vet. App. 258, 264 (2015), holding in reference to continuity and chronicity that "service connection may also be established by showing continuity of symptoms," and one explicitly mentioned element of proof for doing so is "a nexus between the present disability and the post-service symptoms." Emphasis added.

In short, the Board finds the Veteran's statement in 2023 concerning a diagnosis in the 1960s of an ongoing left
1377 (Fed. Cir. 2007) (competence of evidence is a question of fact to be addressed by the Board).

In short, the Board finds the Veteran's statement in 2023 concerning a diagnosis in the 1960s of an ongoing left knee disability is sufficient to show post-service persistence of pain or other symptoms on his in-service injuries. Because arthritis is a chronic disease listed in 38 C.F.R. § 3.309(a), service connection is warranted. The appeal is granted.

3. Entitlement to service connection for chronic kidney disease is denied.

The Veteran contends his chronic kidney disease was caused by in-service toxic exposure risk activities (TERAs) including exposure to lead paint and asbestos. June 2025 NOD; April 2022 VA Form 21-4138 Statement.

The Veteran has a current diagnosis of chronic kidney disease, as conceded by the AOJ in the May 2025 rating decision. The Veteran's STRs are silent for diagnosis or complaints of chronic kidney disease.

A May 2024 memorandum documents that the Veteran had TERAs during service, including exposure to asbestos and lead paint and the AOJ conceded participation in a TERA in the May 2024 rating decision.

A December 2024 VA examination reviewed the Veteran's medical history. In 2011, the Veteran was diagnosed with chronic kidney disease stage 2. Records showed worsening symptoms since the diagnosis, the Veteran was not on dialysis, and the examiner found no functional impact from the kidney disease in August 2024.

The Board has reviewed the medical evidence and finds it consistent with the findings of the VA examination. The record shows the Veteran did not incur chronic kidney disease during service and first sought treatment for the disability decades after service. The Board finds the record does not support finding the chronic kidney disease is connected to service on a direct basis.

Regarding TERA exposures, the examiner considered the Veteran's medical history and in-service toxic exposures. The examiner noted the Veteran has hypertension, which causes kidney disease by impeding the normal function of the kidneys. The Veteran also has prediabetes, another significant risk factor for kidney disease. Based on those factors, the examiner opined that the medical evidence shows kidney disease was less likely than not caused by the Veteran's combined toxic exposures during service.

The Board finds the VA examination probative. The examiner demonstrated an accurate understanding of the Veteran's medical history and provided a rationale that explains the conclusions and gives insight into the medical aspects of the Veteran's disabilities. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

The Board finds the evidence persuasively weighs against finding that the Veteran's chronic kidney disease was caused during or by service, including as caused by toxic exposures, and the benefit-of-the-doubt rule does not apply. This appeal is denied.

4. Entitlement to service connection for elevated liver enzymes is denied.

The Veteran contends his liver condition was caused by in-service TERAs including exposure to lead paint and asbestos. June 2025 NOD; April 2022 VA Form 21-4138 Statement.

The Veteran's STRs and post-service treatment records are silent for liver disease.

A December 2024 VA examination reviewed the Veteran's medical record for evidence of service connection to the claimed liver disability. The examiner found no objective or medical evidence of liver disease. The examiner noted a history of elevated liver enzymes with an onset of March 2024 with no current symptoms.

Abnormal liver enzymes are a laboratory finding and not a disability in and of itself for which VA compensation benefits are payable.

The term disability, as used for VA purposes, refers to impairment of earning capacity. Allen v. Brown,7 Vet. App. 439 (1995); Saunders v. Wilkie,886 F.3d 1356 (Fed. Cir. 2018) (pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability if it reaches the level of a functional impairment of earning capacity). There is no evidence suggesting the Veteran's abnormal liver enzymes cause any functional impairment of earning capacity.

Service connection can be established only for a disability resulting from disease or injury. 38 U.S.C. §§ 1110, 1131. Although there is evidence of abnormal liver enzymes readings since the Veteran's separation, there is no evidence of
, refers to impairment of earning capacity. Allen v. Brown,7 Vet. App. 439 (1995); Saunders v. Wilkie,886 F.3d 1356 (Fed. Cir. 2018) (pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability if it reaches the level of a functional impairment of earning capacity). There is no evidence suggesting the Veteran's abnormal liver enzymes cause any functional impairment of earning capacity.

Service connection can be established only for a disability resulting from disease or injury. 38 U.S.C. §§ 1110, 1131. Although there is evidence of abnormal liver enzymes readings since the Veteran's separation, there is no evidence of a resulting disability. In the absence of proof of a current disability resulting from the abnormal liver enzymes, service connection for abnormal liver enzymes is not warranted. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992).

The Board acknowledges the Veteran's belief that his liver condition was caused by his in-service exposure to asbestos and lead paint. However, in the absence of evidence of a liver disability, a TERA examination was not required. 38 U.S.C. § 1168 (a).

The Board finds that because elevated liver enzymes do not constitute a disability, service connection is not established. This appeal is denied.

5. Entitlement to service connection for allergic rhinitis is denied.

The Veteran contends his allergic rhinitis was caused by in-service TERAs including exposure to asbestos and to red lead paint from scraping old paint from the vessel. June 2025 NOD; April 2022 VA Form 21-4138 Statement.

The Veteran has a current diagnosis of allergic rhinitis, as conceded by the AOJ in the May 2023 rating decision. The issues for the Board are whether the Veteran's rhinitis pre-dated service and if it did, whether his service aggravated the disability beyond its natural progression. The Board must also consider whether the rhinitis was caused by toxic exposures during service.

A veteran is generally presumed to be in "sound condition" at the beginning of service, but an exception to this general rule applies to any "defects, infirmities, or disorders" expressly noted in the relevant paperwork at the time the veteran is accepted for service. 38 U.S.C. §§ 1111, 1137.

That fact alone does not, however, foreclose service-connecting the disability. Where a preexisting disability is noted upon entry into service, a veteran cannot establish service connection based on causation, but may nonetheless demonstrate service-connected aggravation of that disability. 38 U.S.C. § 1153; 38 C.F.R. § 3.306; Wagner v. Principi, 370 F.3d 1089, 1096 (2004).

A pre-existing injury or disease will be considered to have been aggravated in service if there is an increase in the severity of the disability during service, unless there is a specific finding that the increase in disability is due to the "natural progress" of the disease. See 38 U.S.C. § 1153.

Procedurally, the burden is on the veteran to establish their disability got worse during service, but once they have done so, the burden is on the VA to establish by clear and unmistakable evidence the disability got worse due to natural progression. See id.; 38 C.F.R. § 3.306.

In sum, these determinations are based on the weight of the evidence regarding aggravation or worsening of the disability, and VA must meet a higher evidentiary standard than the Veteran.

Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of the disability before, during and after service. 38 U.S.C. § 3.306 (b). Temporary flare-ups of symptoms do not trigger the presumption of aggravation. Davis v. Principi, 276 F.3d. 1341, 1344-45 (Fed. Cir. 2001). As such, showing aggravation of the pre-existing disability by service requires evidence of a permanent substantial change in the severity or degree of the underlying disability rather than the naturally recurring, progressing, and/or temporarily flaring up symptoms. Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991).

"Clear and unmistakable evidence" means that the evidence "cannot be misinterpreted and misunderstood, i.e., it is undebatable." Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). VA must
Principi, 276 F.3d. 1341, 1344-45 (Fed. Cir. 2001). As such, showing aggravation of the pre-existing disability by service requires evidence of a permanent substantial change in the severity or degree of the underlying disability rather than the naturally recurring, progressing, and/or temporarily flaring up symptoms. Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991).

Evidence and analysis

On his September 1966 enlistment examination, the Veteran noted he entered service with hay fever. The Veteran's STRs show no complaints, treatment, or diagnosis for allergies. See May 2022 STR.

The Veteran was denied service connection for his allergic rhinitis in a July 2024 rating decision, and after being denied again on higher level review in an August 2024 rating decision, he appealed that decision to the Board, electing the hearing docket.

During the December 2024 Board hearing, the Veteran testified that his current allergies began in high school and continued through service to the present and that his current rhinitis is what had been called "hay fever." He testified that during service, his symptoms would worsen following exposure to chemicals, blocking his sinuses and causing headaches. The symptoms included nasal congestion, runny nose, itchy eyes and headaches. The Veteran stated that during service, his symptoms were alleviated when the ship was at sea with nothing but pure air with no particles. He did not take medication for his allergies before or during service, but during service he took aspirin for the associated headache. Currently, his symptoms include congestion, runny nose, itchy eyes and headaches and he takes allergy medication. The Veteran reported his symptoms are sometimes better, sometimes the same; in 2023 they were not as bad, noting that perhaps global warming affected the pollen conditions. He also noted that his age makes a difference in the effect of the symptoms. See December 2024 hearing transcript.

In a May 2025 decision, the Board remanded the Veteran's claim for service connection of allergic rhinitis to the AOJ, directing that VA examiners clarify whether: 1) "hay fever" in the record is the same condition as the diagnosed allergic rhinitis; 2) rhinitis was clearly and unmistakably not aggravated during service; and 3) rhinitis at least as likely as not is related to in-service TERA.

For the following reasons, the Board finds the record shows clearly and unmistakably that 1) the Veteran's rhinitis pre-dated his service and 2) his current rhinitis symptoms are a natural progression and were not aggravated by service.

On remand, the May 2025 VA examiner clarified that hay fever is synonymous with allergic rhinitis and that references to hay fever point to the same now-diagnosed allergic rhinitis, and the condition clearly and unmistakably pre-dated service. The examiner therefore opined that the Veteran's current allergies less likely than not were caused by service. A July 2025 VA examination likewise concluded that the current condition is a continuation of the pre-existing condition.

Regarding aggravation, the May 2025 examination noted that the natural course of allergic rhinitis varies per individual but is chronic. The examiner found no evidence of aggravation of the condition beyond its natural course during service, and that the medical evidence over time reflects routine treatment that is the standard of care and should not be considered aggravation beyond the natural course. The examiner opined that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness.

A July 2025 VA examination similarly concluded that given the clear evidence of a chronic nasal congestion/rhinitis condition, subsequent complaints represent flare-ups of the pre-existing allergy condition and there is no substantiating evidence of an unnatural aggravation or exacerbation.

The Board notes that all VA examinations that address the claim for service connection of rhinitis consistently found the record does not demonstrate the Veteran's rhinitis was caused or aggravated by service. See January 2023, July 2024, January 2025 and May 2025 VA examinations. The Board finds the VA examiners' opinions probative on the issues. The examiners demonstrated an accurate understanding of the Veteran's medical history and provided
injury, event, or illness.

The Veteran's in-service and post-service treatment records support these findings. Post-service records over time show the Veteran continued to have allergy symptoms. See, e.g., 1972 annual health assessment for U.S. Navy Reserve (Other), May 2022 STR; October 2018 record, July 2024 CAPRI.

The Veteran testified that during and after service, his allergy symptoms worsened and improved depending on the circumstances, including the environment and ambient air. He reported the same symptoms during service as those he currently experiences, which naturally recur, or temporarily flare up.

In summary, the Board finds the evidence clearly and unmistakably shows the Veteran's allergic rhinitis pre-dated service. The Board also finds the evidence shows the rhinitis clearly and unmistakably was not aggravated by service. See December 2024 hearing transcript; May 2025 VA examination.

TERA exposure analysis

The Board also considered whether the rhinitis was caused by the Veteran's TERA during service and finds the record does not support such a finding.

A July 2025 VA examination reviewed the Veteran's medical history and differentiated the mechanism of allergic rhinitis from illnesses derived from toxic exposures. The examiner noted that allergies involve inflammation of the mucous membranes of the nose, eyes and sinuses, experienced by people who have allergic reactions to extrinsic allergens. Allergens trigger the symptoms identified by the Veteran, including nasal congestion, itching and sneezing. The examiner opined the Veteran's rhinitis less likely than not was caused by toxic exposures in service, finding no objective evidence in the Veteran's record and nothing in medical literature to support the finding that asbestos and other toxic exposures cause allergic rhinitis.

A January 2023 VA examination for respiratory conditions provided additional detail regarding asbestos and the Veteran's rhinitis. The examiner noted the Veteran's service as a clerk had a minimal probability of exposure to asbestos, whereas asbestos conditions require exposure at high levels for long periods to cause illness. Asbestos exposure causes lung illnesses rather than sinus conditions and the Veteran has never been diagnosed with and does not have a respiratory condition. In addition, asbestosis causes shortness of breath and rarely cough or wheezing. The examiner opined the Veteran's sinus condition is not associated with asbestos exposure. See January 2023 VA examination for respiratory conditions.

The Board finds the record persuasively weighs against finding the Veteran's allergic rhinitis was caused by his inservice toxic exposures.

In summary, the Board finds the evidence clearly and unmistakably shows the Veteran's allergic rhinitis pre-dated service and was not aggravated by service and persuasively shows the rhinitis was not caused by in-service toxic exposures. The benefit-of-the-doubt rule is not applicable. This appeal is denied.

6. Entitlement to service connection for gout is granted.

The Veteran contends his gout was caused by in-service exposures to lead paint and asbestos. June 2025 NOD; April 2022 VA Form 21-4138 Statement.

Congress has directed VA to provide a disability examination and medical opinion for veterans who have certain non-presumptive conditions involving a TERA. 38 U.S.C. § 1168 (implementing section 303 of the PACT Act). A VA examination is required when there is evidence of participation in a TERA. Here, the issue of a possible relationship between the Veteran's participation in a TERA and his gout was never explored. Therefore, the Board could remand this issue to the AOJ for another examination and opinion. However, the Board has opted to instead adjudicate the issue based on the evidence that is available.

The Board notes that the TERA Memorandum identifies the Veteran's exposure to lead base paint carries a risk of weakness in fingers, wrists, or ankles. See May 2024 TERA Memorandum. The November 2009 treatment record shows
U.S.C. § 1168 (implementing section 303 of the PACT Act). A VA examination is required when there is evidence of participation in a TERA. Here, the issue of a possible relationship between the Veteran's participation in a TERA and his gout was never explored. Therefore, the Board could remand this issue to the AOJ for another examination and opinion. However, the Board has opted to instead adjudicate the issue based on the evidence that is available.

The Board notes that the TERA Memorandum identifies the Veteran's exposure to lead base paint carries a risk of weakness in fingers, wrists, or ankles. See May 2024 TERA Memorandum. The November 2009 treatment record shows the Veteran's gout, although it occurred several decades after the TERA exposure, manifested in his ankles and hands. See January 2023 VA examination for knee conditions.

Additionally, as noted above, the Veteran reported being told he had gout in "the 1960s." The Board interprets this as referring to the Veteran's time in service, or within one year thereafter. While, as also noted above, this is not corroborated by independent objective evidence, it is important to take into account that this report did not initially come during a VA C&P examination related to his claim, but rather while the Veteran was seeking treatment 15 years before.

This distinction is crucial to the adjudication of the issue because the Board considers statements provided in a patient-to-provider context particularly reliable, credible, and probative because of the obvious motive to be truthful, accurate, and complete when seeking medical diagnosis or treatment. See e.g., White v. Illinois, 502 U.S. 346, 356 (1992) (explaining "a statement made in the course of procuring medical services, where the declarant knows that a false statement may cause misdiagnosis or mistreatment, carries special guarantees of credibility...."). This enhanced trustworthiness is widely and historically recognized, to the extent there is a hearsay exception for such statements in Federal Rule of Evidence 803(4).

While hearsay rules are not binding on the Board, the Board finds the inclusion of this particular exception in the federal rules illustrates a well-established recognition of the inherent self-interest in accurately and comprehensively reporting one's symptoms and medical history in the context of obtaining medical care. Therefore, the Board may consider this rule when assessing the probative value of the Veteran's statements. See e.g., Rucker v. Brown, 10 Vet. App. 67, 73 (1997) ("recourse to the [Federal Rules of Evidence] is appropriate where they will assist in the articulation of the Board's reasons.").

Based on the Veteran's recollection and the TERA memorandum's concession that there may be a connection between in-service exposure to toxins and the Veteran's symptoms, the Board finds it is at least approximately as likely as not the Veteran's gout began during service, which means it is service connected under 38 C.F.R. .303(a). This appeal is granted.

7. Entitlement to a total disability for individual unemployability (TDIU) is granted.

The VA adjudicates claims raised by the evidence as well as those raised by the claimant. Comer v. Peake, 552 F.3d 1362, 1367 (Fed. Cir. 2009). Thus, any claim seeking a rating for a disability may raise the issue of entitlement to a total disability based on individual unemployability (TDIU). Rice v. Shinseki 22 Vet. App. 447, 453-54 (2009). As a result, a claim for a TDIU may be raised by a claim for service connection as well as by a claim for an increased rating. Phillips v. McDonough, 37 Vet. App. 394, 401(2024).

While the Veteran has expressly sought a TDIU, he did so after the period on appeal, and therefore, the Board must determine whether the claims giving rise to the appeal now before it also raised the issue of entitlement to a TDIU. The Board finds the number, diversity, and severity of the conditions in question did raise that issue, and therefore, the Board must analyze whether the Veteran is in fact entitled to a TDIU.

A veteran with a combined schedular disability rating below 100 percent may nevertheless be entitled to a total disability rating in the form of a TDIU if they are unable to secure and follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16; Norris v. West, 12 Vet. App. 413, 420-21 (1999) (a TDIU "an alternate way to obtain a
also raised the issue of entitlement to a TDIU. The Board finds the number, diversity, and severity of the conditions in question did raise that issue, and therefore, the Board must analyze whether the Veteran is in fact entitled to a TDIU.

A veteran with a combined schedular disability rating below 100 percent may nevertheless be entitled to a total disability rating in the form of a TDIU if they are unable to secure and follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16; Norris v. West, 12 Vet. App. 413, 420-21 (1999) (a TDIU "an alternate way to obtain a total disability rating without being rated 100 percent disabled under the Rating Schedule").

The key distinction between a 100 percent disability rating and a TDIU lies in what VA considers when making a decision. Specifically, a 100 percent disability rating under the Rating Schedule is assigned when the hypothetical average veteran would be so impaired by the claimant's disabilities that they would be rendered unemployable. 38 C.F.R. § 4.1. In contrast, a TDIU rating is assigned when the individual veteran filing the claim is actually impaired by their disabilities to the point where they are rendered unemployable. 38 C.F.R. § 4.16.

In other words, the crux of a TDIU analysis is a personalized assessment of whether a veteran's service-connected disabilities render them unable to secure or maintain substantially gainful employment in light of their particular work history, education, skills, and training. Todd v. McDonald, 27 Vet. App. 79, 85 (2014); See also, Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994) (the essential reason for filing a TDIU claim is to address "subjective" factors that "objective" disability ratings do not take into account).

The Veteran last worked in October 2019 or February 2020. He worked in field operation support for a major rental car company. Being unemployable and being unemployed are not synonymous for the purpose of determining entitlement to a TDIU because a Veteran may be unemployed but still capable of securing and maintaining gainful employment.

Unemployability has both an economic component and a non-economic component. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component focuses on whether a given occupation can be considered "gainful"-that is, does it provide employees with an income that is "more than marginal," a bar set by the U.S. Department of Commerce. Specifically, the occupation must pay enough to exceed the poverty threshold for one person. The noneconomic component focuses on whether an individual has the skills and abilities necessary to perform the physical and mental tasks required by a gainful occupation. Factors associated with physical job requirements include the ability to lift, bend, sit, stand, walk, climb, grasp, type, reach, hear and see. Factors associated with mental job requirements include the ability remember, concentrate, adapt, manage stress, work with others, and demonstrate reliability and productivity. These factors do not constitute a checklist; rather, "discussion of any factor is only necessary if the evidence raises it." Id.

When evaluating entitlement to a TDIU, the Board considers each disability's effect on the Veteran's employability, but also the cumulative, synergistic effects of the Veteran's various service-connected disabilities in combination. See, e.g., Floore v. Shinseki, 26 Vet. App. 376, 382 (2013).

As a result of this decision, the Veteran now has service-connected disabilities in his lower extremities that make walking, prolonged standing or sitting, stair climbing, and carrying heavy objects difficult. Prior to this decision, the Veteran was granted service connection for moderate major depressive disorder, bilateral hearing loss, and tinnitus, all of which would make it impractical for the Veteran to work in a position requiring concentration, focus, memory, communication, or collaboration.

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Based on the cumulative impact of the Veteran's various service-connected disabilities, the Board finds he is, under the VA's standards, unemployable. As such, entitlement to a TDIU is granted.

Timothy Cothrel

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Jaeger, L

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.