Citation Nr: 1126940 Decision Date: 07/19/11 Archive Date: 07/29/11 DOCKET NO. 08-05 630 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 10 percent prior to August 19, 2005, and in excess of 40 percent from August 19, 2005, for compression fractures to the T3 and T4 vertebrae with arthritic changes. 2. Entitlement to a rating in excess of 20 percent for thrombophlebitis of the left lower extremity. 3. Whether new and material evidence has been submitted in order to reopen a claim for entitlement to service connection for a cervical spine disorder. 4. Entitlement to service connection for thrombophlebitis of the right lower extremity. 5. Entitlement to service connection for a bilateral knee disorder. 6. Entitlement to service connection for cellulitis of the bilateral lower extremities. 7. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Thomas Knope, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1942 to October 1945. This matter is on appeal from decisions issued in May 2006, and in January 2007, as well as January and August 2000, by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This case was remanded by the Board in May 2010 for further development and, to the extent it is being adjudicated, is now ready for disposition. Because the May 2006 rating decision was not yet final when the RO issued a January 2007 decision addressing an August 2006 claim, the issues are more accurately stated as noted on the title page of this decision and as addressed below. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to service connection for cellulitis in the lower extremities, for thrombophlebitis in the right lower extremity, and for a left knee disorder, as well as entitlement to TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to September 26, 2003, a 10 percent evaluation was the maximum schedular evaluation available for limitation of motion of the dorsal spine, except with demonstrable deformity of a vertebral body, and the preponderance of the medical evidence is against a finding that demonstrable deformity of a vertebral body was present. 2. Resolving reasonable doubt in the Veteran's favor, compression fractures to the T3 and T4 vertebrae with arthritic changes have resulted in pain on all motion of the thoracolumbar spine except forward flexion since September 26, 2003. 3. The Veteran's thoracic disability has not resulted in unfavorable ankylosis of the entire thoracolumbar spine or intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months at any time during the course of this appeal. 4. Prior to July 22, 2010, the Veteran's thrombophlebitis in the left lower extremity was characterized by pain when walking and some instability, but there is no evidence that persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration, was present prior to July 22, 2010. 5. Since July 22, 2010, the Veteran's thrombophlebitis in the left lower extremity has been characterized by pain, persistent edema and stasis pigmentation, however, persistent ulceration was not shown. 6. In March 1999, the RO denied a claim for entitlement to service connection for a cervical spine disorder; this claim was denied by the Board in August 2000 and became final. 7. The additional evidence received since the August 2000 Board decision is not new and material, since this additional evidence is entirely unfavorable and does not raise a reasonable possibility of substantiating the claim for service connection for a cervical spine disorder. 8. A right knee disorder was not manifest during active duty service, within one year of active duty service, or for many years thereafter; the medical evidence is against a finding that a right knee disorder is related to service or to a service-connected disability, and the Veteran's lay statements that right knee symptoms were chronically present are not credible. CONCLUSIONS OF LAW 1. An increased evaluation in excess of 10 percent for compression fractures to the T3 and T4 vertebrae with arthritic changes is not warranted prior to September 26, 2003. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.71, 4.71a, 4.71, 4.71a, Diagnostic Codes 5210, 5235, 5243 (2010); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Code 5010, 5285, 5290, 5291, 5293 (as in effect prior to September 26, 2003). 2. From September 26, 2003, the criteria for a 40 percent rating for compression fractures to the T3 and T4 vertebrae with arthritic changes, have been met, but no criterion for a rating in excess of 40 percent has been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes (DC) 5210, 5235, 5243 (2010); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Code 5010, 5285, 5290, 5291, 5293 (as in effect prior to September 26, 2003). 3. Prior to July 22, 2010, the criteria for a rating in excess of 20 percent for thrombophlebitis in the left lower extremity have not been met, however, since July 22, 2010, the criteria for a 40 percent rating, but not a higher rating, have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.104, DC 7121 (2010). 4. New and material evidence not having been submitted, the requirements to reopen a claim for entitlement to service connection for a cervical spine disorder have not been met. 38 U.S.C.A. §§ 5103, 5103A, 5108, 7105 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.156, 3.159 (2010). 5. A right knee disorder was not incurred in or aggravated by service, nor may such disorder be presumed related to service, nor is a right knee disorder secondary to a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). As to claims for service connection, proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In regards to the increased ratings claims, in a claim for an increased evaluation the VCAA requirement is generic notice, that is, namely, evidence demonstrating a worsening or increase in severity of the disability, the effect that worsening has on employment, and general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In claims to reopen based on new and material evidence, VA must both notify a claimant of the evidence and information that is necessary to reopen the claim and of the evidence and information that is necessary to establish entitlement to the underlying claim for the benefit that is being sought. Kent v. Nicholson, 20 Vet. App. 1 (2006). To satisfy this requirement, VA is required to look at the bases for the denial in the prior decision and to provide the claimant with a notice letter that describes what evidence would be necessary to substantiate those elements required to establish service connection that were found insufficient in the previous denial. Here, the VCAA duty to notify was satisfied by way of a letters sent to the Veteran in January and September 2006 as well as in March 2007 that fully addressed all notice elements, as to claims for service connection and for increased ratings. The March 2007 letter included notice specific to requests to reopen and advised the Veteran of the specific basis of the previous denials of service connection for a cervical spine disorder and informed the Veteran that the claim was denied in the Board decision issued in August 2000. The letters informed him of what evidence was required to substantiate the claims and of his duty to submit or identify evidence and VA's duties for obtaining evidence. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Finally, the notice letter provided to the Veteran in July 2010 included the criteria for reopening a previously denied claim, the criteria for establishing service connection, and information concerning why the claim was previously denied. Consequently, the Board finds that adequate notice has been provided, as he was informed about what evidence was necessary to substantiate the elements required to establish service connection that were found insufficient in the previous denial. With respect to the Dingess requirements, this duty to notify was not satisfied prior to some of the initial unfavorable decision on the claim by the RO. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the RO's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the RO); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). In this case, the Dingess notice was satisfied subsequent to the initial RO decision by way of a letter sent to the Veteran in September 2006 that fully addressed the type of evidence necessary to establish a disability rating or effective date for the disabilities on appeal. Therefore, he was provided the content-complying notice to which he was entitled. Pelegrini, 18 Vet. App. at 122. Furthermore, the claims were readjudicated, and a statement of the case was issued in December 2007 that addressed the affected issues on appeal. Consequently, the Board finds that the duty to notify has been satisfied. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2010). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). First, the RO has obtained the Veteran's service treatment records and VA outpatient treatment records. Further, the Veteran submitted private treatment records and statements from friends regarding the issues on appeal. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Next, VA examinations with respect to the issues on appeal were obtained in July 2010. 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). With respect to the right knee claim, the Board finds that the VA opinion obtained in this case is more than adequate, as it is predicated on a full reading of the private and VA medical records in the Veteran's claims file. It considers all of the pertinent evidence of record, and provides a complete rationale for the opinion stated, relying on and citing to the records reviewed. Regarding the Veteran's increased rating claims, the VA examiners in those examinations considered all of the pertinent evidence of record, to include factors such as the impact of pain on his range of motion, and the statements of the appellant. Moreover, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected thrombophlebitis or thoracic spine disabilities since the most recent VA examination, and the duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. Thus, these examinations are also considered adequate for rating purposes. Next, although the Veteran was afforded a VA examination regarding his cervical spine claim, the Board notes that applications to reopen previously denied claims do not require a specific VA medical opinion or examination in order to consider whether the Veteran has submitted new and material evidence. Rather, the Board has reviewed all the evidence submitted to the claims file since the last final denial. See 38 C.F.R. § 3.159(c)(4)(iii) (2010). Finally, to the extent that it is being adjudicated, this appeal was previously remanded by the Board in May 2010. As relevant here, the Board instructed that the Veteran be provided a VA examination in order to obtain an opinion regarding the nature and etiology of his cervical spine disorder, as well as to ascertain the current extent of his service connected thrombophlebitis and thoracic spine disabilities. The Board is also satisfied there was substantial compliance with the May 2010 Remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Specifically, as noted above, the Veteran was provided with these VA examinations in July 2010, and that examiners provided the requisite opinions. Moreover, as was also explained above, the Board finds these examination and opinions were adequate for adjudication purposes. Accordingly, the Board finds that there is no Stegall violation in this case, and the duties to notify and assist have been met. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1 (2010). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2010). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2010). 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 Veteran. 38 C.F.R. § 4.3 (2010). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the 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 on 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 enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by 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. 38 C.F.R. §§ 4.10, 4.40, 4.45 (2010). The Court of Appeals for Veterans Claims has held that the RO must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The Board notes that the guidance provided by the CAVC in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are as entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See 38 C.F.R. § 4.59 (2010). Next, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Finally, the Court of Appeals for Veterans Claims has held that a rating decision issued subsequent to a notice of disagreement which grants less than the maximum available rating does not abrogate the pending appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Corchado v. Derwinski, 1 Vet. App. 160 (1991). With respect to both his thoracic spine and thrombophlebitis claims, the RO increased the Veteran's disability ratings from 10 to 40 percent and from 10 to 20 percent, respectively. However, in neither case did the RO grant a 100 percent disability rating. Since the RO granted only a portion of the Veteran's increased rating claims, his appeal properly remains before the Board for review. 1. Compression Fractures to the T3 and T4 Vertebrae with Arthritic Changes Historically, the Veteran was awarded service connection for compression fractures of the dorsal (thoracic) spine at T3 and T4, by a rating decision issued in 1999. In March 2002, the Veteran sought special monthly compensation based on the need for aid and attendance or at the housebound rate. This claim was accepted as a claim for an increased rating for the service-connected thoracic spine disability, which was then evaluated as 10 percent disabling. By a rating decision issued in May 2006, the 2002 claim for an increased evaluation for the thoracic spine disability was granted, in part, and an increased evaluation to 40 percent was granted, effective August 19, 2005. In August 2006, the Veteran sought a total disability evaluation based on individual unemployability (TDIU). This claim was accepted by the RO as a claim for an increased rating for the thoracic spine disability. However, the May 2006 rating decision had not yet become final. Therefore, the period of appeal, as to the claim for an increased evaluation for thoracic spine disability, must include the period covered by the May 2006 rating decision, that is, from March 25, 2002. A. Evaluation prior to September 26, 2003 As to the period from March 25, 2002, through September 26, 2003, the Board notes that the Veteran's thoracic spine disability was evaluated as 10 percent disabling under DCs 5285 and 5010. DC 5285, as in effect on March 25, 2002, provided that the disability was to be rated in accordance with definite limited motion or muscle spasm, adding 10 percent for demonstrable deformity of the vertebral body. DC 5291 provided that limitation of motion of the dorsal spine warranted a noncompensable rating if the limitation was slight, a 10 percent rating if the limitation was moderate, and a 10 percent rating if the limitation was severe. 38 C.F.R. § 4.71a (as in effect prior to September 26, 2003). As of September 26, 2003, the criteria for evaluating spine disabilities was changed to provide for the evaluation of all spine disabilities under a General Rating Formula for Diseases and Injuries of the Spine, unless the disability is rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (renumbered as Diagnostic Code 5243), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Because the provisions governing evaluation of spine disability changed on September 26, 2003, the Board must separately consider the appropriate evaluation for the Veteran's thoracic disability during the period of the appeal prior to September 26, 2003, as compared to the evaluation after that date. In particular, the Board notes that it must consider whether the Veteran is entitled to an increased evaluation in excess of 10 percent under the old version of the regulations prior to September 26, 2003. The amended regulations may not be considered to assign an increased evaluation prior to September 26, 2003, since the amended regulations were not effective prior to that date. However, as discussed below, the Board must consider whether an increased evaluation is assignable at any time during the appeal period under the regulations in effect in 2002, when the Veteran filed the claim which should be considered the basis of this appeal. Under DC 5291, as in effect prior to September 26, 2003, a 10 percent evaluation is the maximum schedular evaluation for limitation of motion of the dorsal spine. The Board must next consider whether the Veteran is entitled to a separate, 10 percent evaluation for demonstrable deformity of the vertebral body. In this case, radiologic examination conducted in March 2003 disclosed no deformity of the vertebral body of any thoracic vertebra. The Board has also reviewed the evidence from radiologic examinations conducted prior to 2002, including in 1999. Those radiologic examinations disclose no notation that there was demonstrable deformity of a thoracic vertebral body. The Board has also considered each radiologic examination conducted throughout the course of the appeal, since the "old" version of the regulation is applicable throughout the appeal. However, no radiologic examination was interpreted as showing demonstrable deformity of a vertebral body. The 2009 radiologic examination disclosed mild to moderate degenerative disc disease. In particular, the examination disclosed that there was less than 10 percent loss of height. This evidence establishes that demonstrable deformity of a vertebral body is not present. A 10 percent evaluation is the maximum schedular evaluation available under DC 5291 for limitation of motion of the thoracic spine. Where an appellant is already receiving the maximum disability rating for limitation of motion, consideration of the provisions of DeLuca v. Brown, 8 Vet. App. 202 (1995) (functional impairment due to pain must be equated to loss of motion) is not required. Johnston v. Brown, 10 Vet. App. 80, 85 (1997); see also VAOPGCPREC 36-97. Thus, the veteran's complaints of pain do not warrant an evaluation in excess of 10 percent during this period. The Board has considered whether a separate, additional evaluation, is available under any other DC. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, there is no medical evidence that any provider assigned a diagnosis of interveteral disc disease, so DC 5293, the only DC that might provider an increased evaluation under the circumstances of this case, is not applicable. There is no evidence which demonstrate that the rating schedule, with application of the maximum schedular evaluation, is inadequate for determining the proper level of disability. In particular, the Board finds no evidence of any sign or symptom of thoracic disability which is not encompassed within the maximum schedular evaluation already assigned. Therefore, the Board finds that the criteria for submission for an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Thun v. Peake, 22 Vet. App. 111 (2008). B. Evaluation from September 26, 2003 through August 19, 2005 There is no specific evidence of the Veteran's thoracic or lumbosacral spine motion during the period from September 26, 2003 through August 19, 2005. The Veteran was afforded VA examination in February 2006. At that time, he exhibited 35 degrees of forward flexion and 10 degrees or less in bilateral rotation. The RO determined that this range of motion warranted a 40 percent evaluation under the revised regulations in effect in 2005. As there is no evidence that the Veteran's motion was better from September 26, 2003 through August 19, 2005 than it was in February 2006, resolving doubt in the Veteran's favor, a 40 percent evaluation is warranted for this period. However, the evidence does not demonstrate that the Veteran sought evaluation for unfavorable ankylosis or incapacitating episodes having a total duration of at least 6 weeks during any 12 month-period from September 26, 2003 through August 19, 2005. A 40 percent evaluation is the maximum schedular evaluation available for limitation of motion of the thoracolumbar spine. Therefore, a rating in excess of 40 percent is not for application. See Johnston v. Brown, 10 Vet. App. 80 (1997) (if a claimant is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable). The Board finds no evidence of any sign or symptoms of disability which is not encompassed within the rating schedule or within the increased evaluation to 20 percent based on pain. Therefore, the Board finds that the criteria for submission for an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Thun v. Peake, 22 Vet. App. 111 (2008). C. Evaluation from August 19, 2005 From August 19, 2005, the Veteran has been awarded a 40 percent rating under 38 C.F.R. § 4.71a, DCs 5210 and 5235 (addressing vertebral fracture or dislocation). Under these diagnostic codes, spine disabilities are rated primarily under a general formula for rating intervertebral disc syndrome which is also contained in 38 C.F.R. § 4.71a. Under this formula, in order to warrant a rating in excess of 40 percent, the evidence must show unfavorable ankylosis of the entire thoracolumbar spine (50 percent). For VA purposes, ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." See Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). In the alternative, a rating in excess of 40 percent may also be for application in cases where the evidence indicates intervertebral disc syndrome with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months (60 percent under DC 5243). Specifically, Note (1) to the general rating formula defines an incapacitating episode as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. In this case, however, a rating in excess of 40 percent is not warranted. First, throughout the course of the appeal, ankylosis has not been shown. While the Board recognizes that the Veteran has significant impairment in his range of motion in this thoracolumbar spine, immobility of the spine has not been demonstrated. Specifically, at a VA examination in February 2006, he exhibited 35 degrees of forward flexion and 10 degrees or less in bilateral rotation. Next, at a VA examination in April 2007, he exhibited 55 degrees of forward flexion, 12 degrees of extension, right flexion of 24 degrees, left flexion of 18 degrees and 20 degrees of rotation bilaterally. Somewhat similar results were noted at another VA examination in February 2009. Moreover, although the Veteran had asserted that his spine disability had worsened since the February 2009 VA examination, a VA examination in July 2010 did not indicate ankylosis, or even that his range of motion had significantly worsened. At that time, he exhibited 50 degrees of flexion, 15 degrees of extension, 15 degrees of bilateral flexion, and at least 20 degrees of rotation in each direction. More importantly, in each case, the examiner specifically stated that there was no ankylosis of the thoracolumbar spine. Therefore, a rating in excess of 40 percent is not warranted on this basis. Additionally, with regard to the impact of pain on his range of motion, the Board is sensitive to the fact that the Veteran clearly experiences a profound limitation. However, he is currently in receipt of the maximum schedular evaluation for limitation of motion of the thoracolumbar spine. Therefore, a discussion of the effects DeLuca, 8 Vet. App. at 202, is not necessary since any consideration regarding complaints of weakness, fatigability or loss of function due to pain cannot result in a higher disability evaluation. See Johnston v. Brown, 10 Vet. App. 80 (1997) (if a claimant is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether 38 C.F.R. §§ 4.40 and 4.45 are applicable). Next, the Veteran's symptoms have not been indicative of incapacitating episodes involving periods of bed rest and treatment by a physician for a duration of six weeks over the last 12 months. In this case, the Veteran has a number of disorders that has significantly limited his daily living. However, a review of his VA treatment records for is conspicuously absent for any findings of physician prescribed bed rest. At best, the evidence indicates episodes of "flare-ups" which occur on occasion and last only one to two days at a time. However, the evidence did not indicate the presence of long-term episodes that impaired his ability to perform daily activities. It is noted that the Veteran mentioned, at his VA examination in February 2009, occasions where he could not get out of bed due to his flare-ups and that he used a urinal that was at his bedside. However, the Board does not construe these episodes to be extended periods of incapacitation. As mentioned above, the evidence does not indicate that any of these flare-ups lasted longer than 48 hours, nor was any period of bed rest prescribed by a physician. Therefore, a rating in excess of 40 percent is also not warranted on this basis. Next, the Board has considered whether a separate evaluation is warranted for any associated neurological abnormality. Under 38 C.F.R. § 4.71(a), any associated objective neurologic abnormalities, including bowel or bladder impairment is also to be evaluated under the appropriate diagnostic code. See 38 C.F.R. § 4.71(a) (2009). However, a separate evaluation is not warranted, as neurological abnormalities have not been shown. Specifically, throughout the period on appeal, the Veteran's strength in the extremities has been normal. Specifically at VA examinations in February 2006, April 2007 and February 2009, his strength was observed to be normal. Moreover, the evidence does not indicate that the Veteran experiences any bladder or bowel incontinence whatsoever that is attributable to his service-connected disability. The VA examinations do indicate the presence of diminished sensation in the lower extremities. Specifically, at the February 2009 VA examination, the examiner observed decreased sensitivity although, as noted above, his strength in the lower extremities was normal. The Veteran also complained of numbness in the extremities. However, the examiner believed that these symptoms were attributable to the Veteran's B-12 deficiency and history of diabetes mellitus, rather than to his service-connected back disability. Moreover, while similar sensory deficiency was noted at the July 2010 VA examination, the examiner was unable to determine whether it was due to his spine disorder or to another etiology. However, as the other evidence of record does not indicate radiculopathy that is due to the Veteran's spine disorder, a separate rating based on neurological disorders is not for application. Therefore, in view of the competent evidence of record for the period on appeal, the Board concludes that the evidence does not show unfavorable ankylosis or incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Therefore, a rating in excess of 40 percent is not for application. 2. Thrombophlebitis of the Left Lower Extremity Next, the Veteran is currently rated at 20 percent for the service-connected thrombophlebitis in his left leg under 38 C.F.R. § 4.104, DC 7121 (addressing post-phlebitic syndrome of any etiology). Under DC 7121, a 20 percent rating is assigned when a disability attributed to venous disease is manifested by persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema. In order to warrant a rating in excess of 20 percent, the evidence must show persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration (40 percent under DC 7121). In this case, the Board concludes that, prior to his VA examination in July 2010, a rating in excess of 20 percent is not warranted. Specifically, prior to July 2010, the Veteran underwent three VA examinations specifically directed toward the thrombosis in his left lower extremity. On all three occasions, the examiner's noted the presence of edema, although it is unclear whether such edema could be characterized as "persistent" and could not be resolved by elevation. Most importantly, however, a rating in excess of 20 percent prior to July 2010 is not warranted as none of these examinations indicated the presence of persistent pigmentation or eczema. In fact, during all three VA examinations in February 2006, April 2007 and February 2009, no stasis pigmentation or eczema was noted upon examination. Therefore, as discoloration or eczema was not shown prior to July 2010, a rating in excess of 20 percent is not for application. However, when the Veteran underwent a VA examination on July 22, 2010, the examiner observed the presence of persistent skin discoloration. As this discoloration was not present in previous VA examinations, it represents a worsening of the Veteran's condition. Moreover, while the Board notes that this same VA examiner did not believe that the Veteran's edema was persistent, this was noted at the time of the examination, and the previous VA examinations consistently noted edema on each occasion. In the Board's view, the Veteran's edema can be characterized as persistent. While the VA examiner in July 2010 noted a medical evaluation in March 2010 which did not note edema in the extremities, this is outweighed by the consistent observation of edema at each of the prior VA examinations, which were directed specifically toward the Veteran's disability. Therefore, as the evidence indicates the presence of edema and discoloration at the July 2010 VA examination, and in view of the Board's conclusion that both are persistent in nature, a 40 percent rating is warranted from July 22, 2010. Next, the Board must consider whether a rating in excess of 40 percent is warranted since July 22, 2010. Under 38 C.F.R. § 4.104, DC 7121, a rating in excess of 40 percent is for application when the evidence shows persistent edema or subcutaneous induration, stasis pigmentation or eczema and persistent ulceration (60 percent). However, based on the evidence since July 22, 2010, a 60 percent rating is not warranted. Specifically, while persistent edema and discoloration have been shown, the evidence has not shown the presence of persistent ulceration. Certainly, the evidence indicates that the Veteran experiences occasional ulcerations. However, as was noted at the VA examination in July 2010, the frequency of ulceration was only 2 to 3 times per year. Therefore, a rating in excess of 40 percent since July 22, 2010 is not warranted. With regard to both of these increased rating claims, the Board has also considered the Veteran's statements that his disabilities are worse than the ratings he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability of his thrombophlebitis or thoracic spine disabilities according to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's disabilities have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. Next, the Board will consider whether referral for an extraschedular evaluation is warranted. The question of an extraschedular rating is a component of a claim for an increased rating. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Court of Appeals for Veteran's Claims has clarified the analytical steps necessary to determine whether referral for such consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. In this case, the evidence does not indicate that Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. Specifically, the Veteran's disabilities were applied to the applicable rating criteria, general counsel opinions, and case law. Although the diagnostic codes in this case allow for higher ratings, the Board fully explained why the higher ratings were not warranted. Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran's thrombophlebitis or thoracic spine disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In sum, after a careful review of the evidence of record, the Board finds that the benefit of the doubt rule is not applicable and these appeals are denied. New and Material Evidence In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. Manio v. Derwinski, 1 Vet. App. 140 (1991). Under the relevant regulation, "new" evidence is defined as evidence not previously submitted to agency decision-makers. "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. When determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). However, lay assertions of medical causation cannot serve as the predicate to reopen a claim under 38 U.S.C.A. § 5108. See Moray v. Brown, 5 Vet. App. 211, 214 (1993). 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. 38 C.F.R. § 3.156(a). If it finds that the submitted evidence is new and material, VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the Veteran in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999); but see 38 U.S.C.A. § 5103A (eliminates the concept of a well-grounded claim). Because the Board has the jurisdictional responsibility to consider whether it was proper to reopen the claim, regardless of the RO's determination on the question of reopening, the Board will determine whether new and material evidence has been received and, if so, consider entitlement to service connection on the merits. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). 3. Request to reopen claim for cervical spine disorder The Veteran is claiming entitlement to service connection for degenerative changes in the cervical spine, to include as due to his service connected thoracic spine disability. As was noted in the Board's prior decision in May 2010, the RO denied this claim in March 1999 on the basis that a relationship between his current disorder and either active duty or his thoracic spine disability was not shown through the competent evidence. Although this claim was appealed by the Veteran, it was ultimately denied by the Board in August 2000. The Veteran was advised of the Board's decision, but he did not initiate an appeal to the United States Court of Appeals for Veterans Claims. Therefore, the August 2000 Board decision is final. U.S.C.A. § 7104 (West 2002); 38 C.F.R. § 20.1100 (2010). The evidence at the time of the Board's August 2000 decision included the Veteran's service treatment records and VA treatment records from 1996. The evidence also included VA examination reports from December 1998 and February 1999. Additionally, the Veteran submitted a number of statements from friends and physicians who recalled the Veteran being injured to the back and neck while on active duty, although these statements were all made many years after he left active duty. The evidence of record at the time of the initial decision included VA treatment records from August 1999 to October 2002 and from May 2004 through August 2010. Moreover, the Veteran underwent VA examinations in March 2003, February 2004, February 2009 and July 2010. Additionally, he also submitted records of private treatment from October 2003, December 2004 and November 2005. All of the above evidence is "new," in that it was not previously considered by the RO or the Board prior to the last final denial. However, the Board concludes that none of it is "material," it does not relate to an unestablished fact necessary to support the claim. Specifically, much of this new evidence addresses either the Veteran's service-connected thrombophlebitis in the left leg or his service-connected thoracic spine disability. Of particular note, the most recent VA treatment records in 2010 address cardiovascular treatment almost exclusively, and are not relevant to any of the issues that are addressed in this decision. Of these records, only a few are even tangentially relevant to the Veteran's cervical spine complaints. Specifically, at his March 2003 VA examination, he complained of having difficulty in turning his head and experiencing pain in his neck, and the subsequent examination revealed a diminished cervical spine range of motion. Moreover, an X-ray of the cervical spine in July 2005 confirmed the presence of degenerative arthritis in the cervical spine. However, the fact that the Veteran has a current cervical spine disorder has already been established. On the other hand, this evidence does not establish the presence of a chronic cervical spine disorder while in service, nor does it establish that his current cervical spine disorder is related to either active duty or to a service connected disability. Therefore, while this evidence is "new" in that it has not been previously considered by the RO, it is nonetheless not material, as it does not relate to an unestablished fact necessary to support the claim. After this claim was remanded by the Board in May 2010, the Veteran underwent a new VA examination in July 2010 in order to consider whether his cervical spine disorder is related to active duty service. Based on the supplemental statement of the case sent to the Veteran in March 2011, it appears that the RO reopened the claim based on the results of this examination. However, the Board concludes that none of the information contained in this new VA examination is material, as it does not relate to an unestablished fact necessary to support the claim. Specifically, while the Veteran was again diagnosed with degenerative arthritis of the cervical spine, the examiner nonetheless provided the opinion that this was not caused by, or is a result of, his active duty service or to a service-connected disability. In providing this opinion, the examiner reflected that there was no evidence of an actual neck injury while in service, nor were there any records indicating neck symptomatology for many years thereafter. Moreover, the examiner also stated that none of the generally accepted medical literature supports the concept that a cervical spine disorder may be attributable to thoracolumbar osteoarthritis or to a post-phlebitic condition. Therefore, while this VA examination is "new" in that it did not exist at the time of the last final denial of this claim, it is nevertheless not material, because it does not provide any support to an unestablished fact necessary to support the claim. In particular, the evidence is against a finding that a chronic cervical spine disorder existed in service, or that the Veteran's current disorder is attributable to either active duty or to a service-connected disorder. Finally, the new evidence includes additional statements about the Veteran's condition. Specifically, the Veteran has complained of neck pain since his fall from a ladder on board his ship in 1945. However, his statements of continuous cervical spine symptoms since that time are something that would have been considered by the Board in its August 2000 decision. Thus, any additional assertions of such symptoms are redundant. Moreover, any statements made by the Veteran asserting that his cervical spine disorder is attributable to active duty or to a service-connected disability would not be sufficient to reopen the claim, as a lay person is not competent to offer an opinion that requires medical expertise, and consequently the statements do not constitute new and material evidence to reopen the claim. Moray v. Brown, 5 Vet. App. 211, 214 (1995) (holding that lay assertions of medical causation cannot serve as a predicate to reopen a previously denied claim). Consequently, in this case, the Board finds that none of the current evidence submitted by the Veteran since the final rating decision is new and material under 38 C.F.R. § 3.156(a). Thus, the Veteran's application to reopen a claim of entitlement to service connection for a cervical spine disorder must be denied. As noted above, it appears that the RO assumed that the additional evidence was new and material. The Board notes that, as all the additional evidence obtained since the last final determination is entirely negative, a determination that the evidence is new and material is, in fact, no more favorable to the Veteran than a determination that the evidence is not new and material. The Board acknowledges that, under the current version of the governing regulation, the threshold for evidence required to meet the definition of new and material evidence is low. Shade v. Shinseki, 24 Vet. App. 110 (2010). However, the Board is unable to find any item of evidence which meets this low threshold. In short, as the additional evidence offers no possibility of substantiating the claim, it is not new and material, and the claim is not reopened. Entitlement to Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Moreover, under 38 C.F.R. § 3.303(b), the second and third elements of Shedden and Caluza may be established through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). Also, in the context of arthritis, this disorder may be presumed to have been incurred in service if shown to have manifested to a compensable degree within one year after the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Finally, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). 4. Claim for service connection for right knee disorder Service treatment records reflect no complaints of, treatment for, or a diagnosis related to either knee while on active duty, or any symptoms reasonably attributed thereto. At the time of discharge, the clinical evaluation of the Veteran's knees was normal. Therefore, no chronic disorder to either knee was noted in service. Next, post-service evidence does not reflect right knee symptomatology for many years after service discharge. Specifically, the first positive indication of a right knee disorder was not until July 2005, where radiographic imaging indicated moderate degenerative joint disease. In this case, the Board emphasizes the fact that this diagnosis is approximately 60 years after he left active duty. As noted above, the Veteran underwent a separation physical examination in 1945 that did not note a knee disorder of any kind. The Veteran submitted claims for service connection in 1951 and 1983. In 1989, the Veteran testified at personal hearings at the RO. The Veteran submitted another claim in 1990. He testified at a personal hearing in 1991. He was afforded VA examination in 1991. At that time, there was minimal degenerative joint disease of the left knee. However, the Veteran did not report that he had injured the right knee in service and no complaint of right knee pain or right knee abnormality was noted on physical examination, which included examination of both lower extremities. There is no evidence that the Veteran sought private or VA treatment of a right knee disorder until more than 40 years elapsed after his service discharge. Therefore, a continuity of symptoms has not been established based on the competent evidence. Also, as the first indication of a right knee disorder occurred approximately 60 years after active duty service, the evidence does not indicate the presence of arthritis in the knee within one year of active duty. Therefore, service connection on a presumptive basis is not for application. See 38 C.F.R. § 3.307, 3.309 (2010). In addition to the documented post-service treatment records, the evidence includes the Veteran's statements asserting continuity of symptoms. In such cases, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this regard, it is true that the Veteran is competent in some cases to self-diagnose some disorders despite his status as a lay person. However, he is not competent diagnose a disorder such arthritis of the knees as it is not a disorder that may be diagnosed by its unique and readily identifiable features, and thus requires a determination that is "medical in nature." See Jandreau v. Nicholson, 492 F.3d 1372, 1377 at n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer.") Nevertheless, the Veteran's lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection, if credible, regardless of the lack of contemporaneous medical evidence. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, the Board determines that the Veteran's reported history of continued symptomatology of the right knee since active service, while competent, is nonetheless not credible. In making this determination, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). Significantly, the Board finds that the Veteran's reported history of continued knee symptomatology since active service is inconsistent with the other evidence of record. Indeed, while he stated that his disorder began in service, the separation examination was absent of any complaints. Moreover, as noted above, while he submitted a claim for benefits for other disorders in 1946, he did not claim a knee disorder at that time. Caluza, 7 Vet. App. at 498. Further, as noted, the Veteran submitted several claims over the years in the period between 1950 and 1990, without describing or claiming any injury to the right knee. The record of the Veteran's statements from 1950 through 1990, including his testimony at personal hearings, is inconsistent with his current contentions regarding the right knee. Moreover, there is no evidence that the Veteran sought medical evaluation for right knee symptoms during this period. The contrast between the Veteran's inaction with respect to medical evaluation of right knee symptoms during the 40 years following his service and his current contentions renders the current contentions not credible. Thus, the Board has weighed the Veteran's statements as to continuity of symptomatology against the failure to raise this issue when submitting other claims for benefits and finds his recollections as to symptoms experienced in the distant past, made in connection with a claim for benefits, to be less probative. Therefore, continuity has not here been established, either through the competent evidence or through his statements. Next, service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran's right knee disorder to active duty, despite his contentions to the contrary. To that end, the Board places significant probative value on a July 2010 VA examination undertaken specifically to address the issue on appeal. At that time, the Veteran reported experiencing pain when trying to walk, and he ambulated primarily via motor scooter. After a physical examination, to include radiographic imaging of the knee, the examiner diagnosed osteoarthritic changes with joint space narrowing in the lateral compartment. However, the examiner opined that it was less likely than not that the Veteran's arthritis in the right knee was caused or aggravated by either his active duty service or to a service connected disability. In providing this opinion, the examiner reflected that there was "no evidence" of a knee injury in service or any evidence of a knee disorder for many years following active duty. Moreover, the examiner stated that the available medical literature does not support the argument that osteoarthritis of the knee may be attributable to his service-connected thoracolumbar spine disability. The Board finds that the examination was adequate for evaluation purposes. Specifically, the examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination. There is no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. Additionally, while it should be noted that the examiner did not specifically provide the opinion regarding the relationship between his right knee disorder and his service-connected thrombophlebitis, the Veteran has never asserted such a relationship other than that they are both the result of the same accident that occurred while on active duty. Therefore, the Board finds the VA examiner's opinion to be of great probative value. Finally, the Board has also considered the statements made by the Veteran relating his right knee disorder to his active service. The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)). In this case, however, the Veteran is not competent to provide testimony regarding the etiology of his right knee disorder. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 at n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). Because osteoarthritis is not diagnosed by unique and readily identifiable features, it does not involve a simple identification that a layperson is competent to make. Therefore, the unsubstantiated statements regarding the claimed etiology of the Veteran's right knee disorder are found to lack competency. In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. ORDER An increased evaluation in excess of 10 percent for compression fractures to the T3 and T4 vertebrae with arthritic changes prior to September 26, 2003, is denied. An increased rating from 10 percent to 40 percent is granted from September 26, 2003 through August 19, 2005, subject to law and regulations governing the effective date of an award of monetary compensation; the appeal is granted to this extent only. An evaluation in excess of 40 percent for compression fractures to the T3 and T4 vertebrae with arthritic changes, from August 19, 2005, is denied. A rating in excess of 20 percent for thrombophlebitis of the left lower extremity prior to July 22, 2010 is denied. From July 22, 2010, a 40 percent rating, but not more, for thrombophlebitis of the left lower extremity, is granted, subject to governing criteria applicable to the payment of monetary benefits; the appeal is granted to this extent only. New and material evidence having not been submitted, the application to reopen a claim for entitlement to service connection for a cervical spine disorder is denied. Service connection for a right knee disorder is denied. REMAND As for the remaining claims on appeal, the Board has determined that additional development is necessary before they can be adjudicated. 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2010). As an initial matter, in its May 2010 remand, the Board required that the Veteran undergo a VA examination in order to determine the nature and etiology of the disorders to his right and left lower extremities. As part of this requirement, the Board specifically asked the examiner to provide an opinion as to whether it was "at least as likely as not" (i.e. a 50 percent probability or greater) that the Veteran's cellulitis and thrombophlebitis was attributable to active duty service or to a service-connected disability. While the examiner stated that the Veteran's service-connected disabilities did not cause these particular disorders, she declined to provide an opinion as to whether the thrombophlebitis in the right lower extremity or the cellulitis in lower extremities are due to his accident while on active duty service. Her reasoning was that a disorder in the right lower extremity was not shown at that time. In such instances where an opinion cannot be provided, it must be clear, from either the examiner's statements, or the Board decision, that the examiner has indeed considered "all procurable and assembled data" by obtaining all tests and records that might reasonably illuminate the medical analysis. Conversely, when the record leaves this issue in doubt, it is the Board's duty to remand for further development. Jones v. Shinseki, 23 Vet. App. 382, 389-90 (2010); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In this case, the examiner's findings notwithstanding, the evidence of record nevertheless indicates that the Veteran has been diagnosed with deep vein thrombosis in the right lower extremity for many years, and has also consistently displayed thrombophlebitis-type symptoms such as edema and prior skin ulcerations. Moreover, nothing in the evidence prior to the VA examination in July 2010 suggests that this disorder is likely to improve. Therefore, the fact that he has a current disorder in the right lower extremity is already established. Accordingly, it would be more helpful if the examiner would provide an addendum opinion where a current disability is presumed present. Additionally, when providing this addendum opinion, the examiner should provide a medical explanation regarding the relationship between deep vein thrombosis, thrombophlebitis and cellulitis and, similarly, discuss the likelihood that the Veteran's diagnosis of cellulitis in the right and left lower extremities in 1943 was related to a current lower extremity disorder or was an indicator of a chronic deep vein thrombosis disorder. The examiner is asked to provide an opinion as to whether the disorder manifested in service was chronic in nature. The examiner should discuss the effect of coronary bypass surgeries on any chronic lower extremity disorder, if such disorder was present prior to those surgeries. Next, regarding the Veteran's left knee disorder, a VA examiner provided an opinion in July 2010 stating that this was not related to active duty or to a service-connected disability. In support of this opinion, the examiner noted the absence of any treatment in service or for many years thereafter to the left knee. However, during that VA examination, the Veteran indicated that he underwent surgery to his left knee at Emory University approximately 5 to 7 years following active duty. The Veteran also previously mentioned this surgery at a VA examination in 1991, stating that he had some left knee cartilage removed in approximately 1955. The Board concludes that there is sufficient information to make an attempt to acquire these records, and such an attempt should be made prior to adjudication of the claim. Finally, while the Veteran has also submitted a claim for TDIU, for the reasons explained above, his disability picture has since changed. Thus, the claim for TDIU is inextricably intertwined, and cannot be considered until a more recent picture of the Veteran's symptomatology is acquired. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Additionally, the Board also finds that further development is necessary prior to adjudicating the claim for TDIU. In this regard, a grant of TDIU benefits is based upon a showing that the Veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2010). However, whether the Veteran's service connected disabilities, either alone or in aggregate, prevent him from obtaining and maintaining substantially gainful employment is a question that must be determined by a medical professional, and not the Board. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (When the medical evidence of record is insufficient, in the opinion of the Board, or of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions). In this case, "substantially gainful employment" is defined as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran's earned annual income. See Faust v. West, 13 Vet. App. 342 (2000). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). Expedited handling is requested.) 1. Obtain current VA treatment records, the VA Medical Center in Gainesville, Florida, or any other VA facility, for the period from May 2010 to the present. The Veteran should also be asked to provide information regarding any private treatment he has received since that time (May 2010) which has not been incorporated into the record. 2. The Veteran should be asked to provide any information relating to the left knee surgery he underwent at Emory University in approximately 1955. Moreover, the AMC should attempt to acquire any related records from Emory University in Atlanta, Georgia, after receiving the Veteran's authorization. 3. Since it unlikely that private clinical records prior to 1960 are available, the Veteran should be afforded an opportunity to identify any records or information of any type that is not already of record, especially any official record, such as from physical examination for purposes of insurance, education, or employment, that notes prior history of knee surgery, especially proximate to his service, that might substantiate his claim that he had knee surgery soon after service. 4. If any records from Emory University are acquired, or any relevant evidence, if not duplicative of evidence already of record, and which tends to substantiate the claim, is obtained on Remand, this claim should be forwarded to the VA examiner who provided the opinion in July 2010 regarding the Veteran's left knee. The examiner should be asked if this new evidence alters his original opinion. 5. Forward to the claims folder, and a copy of this remand, to the examiner who examined the Veteran's lower extremities in July 2010. Then, the examiner is asked to provide an addendum to the opinion as to whether it is at least as likely as not (i.e. a 50 percent probability or greater), that the Veteran's current bilateral cellulitis and the deep vein thrombosis in his right lower extremity are etiologically related to active duty service. As part of this addendum, the examiner is asked to provide details as to the likelihood that the Veteran's diagnosis of cellulitis in the right and left lower extremities in 1943 is etiologically related to a current lower extremity disorder, and as to the likelihood that cellulitis in the right and left lower extremities diagnosed in 1943 became chronic, and as to the likelihood that cellulitis in the right and left lower extremities diagnosed in 1943 is etiologically related to or an indicator of deep vein thrombosis or thrombophlebitis. Also, the examiner is also asked to provide an opinion as to whether these disorders are chronic in nature and, if so, what effect the Veteran's subsequent coronary bypass surgeries would have had on the circulation in his lower extremities. If the examiner who provided the July 2010 opinion is unavailable, this remand should be forwarded to another VA examiner for the appropriate action. A new examination is not necessary unless deemed so by the examiner. 6. AFTER all claims for service connection have been adjudicated, and all actions described in paragraphs #1 through #5 have been conducted, the agency of original jurisdiction should review the list of disabilities for which service connection has been granted, and should verify that a contemporaneous VA examination which identifies the effect of each service-connected disability on the Veteran's ability to perform the activities required for gainful employment. If contemporaneous clinical evidence as to the effect of any service-connected disability on the Veteran's ability to perform tasks required for gainful employment is not of record, schedule the Veteran for appropriate examination(s as necessary to adjudicate the effect of the Veteran's service-connected disabilities on his ability to obtain and retain substantially gainful employment, specifically, his ability to perform tasks required for manual labor, as a machinist or in construction, or in other employment similar to the Veteran's experience in those fields. The examiner is requested to offer an opinion as to the tasks required for sedentary employment which would be precluded by the Veteran's service-connected disabilities. 7. Thereafter, readjudicate the appeal. If the decisions remain in any way adverse to the Veteran, he and his representative should be provided with a supplemental statement of the case (SSOC). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ TRESA M. SCHLECT Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs