Citation Nr: 1310801 Decision Date: 04/02/13 Archive Date: 04/11/13 DOCKET NO. 10-34 511 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to an increased rating in excess of 20 percent for recurrent subluxation or lateral instability of the left knee. 2. Entitlement to an increased rating in excess of 20 percent for status-post left patella fracture with arthritis and malunion of the patella. 3. Entitlement to service connection for type 2 diabetes mellitus, including as secondary to the service-connected left knee and left ankle disabilities. 4. Entitlement to service connection for low back pain. 5. Entitlement to service connection for erectile dysfunction, to include as due to medications taken for service-connected left knee and ankle disabilities. 6. Entitlement to service connection for left a left wrist disorder, claimed as arthritis of the left wrist. 7. Entitlement to service connection for a right wrist disorder, claimed as arthritis of the right wrist. 8. Whether new and material evidence has been received to reopen service connection for hypertension. ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active duty service from August 1984 to July 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. The issues of entitlement to service connection for type 2 diabetes mellitus and service connection for a right wrist disorder 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. As the Board finds the claim for service connection for erectile dysfunction to be inextricably intertwined with the claim for service connection for diabetes mellitus, that issue is also addressed in the REMAND portion of the decision. FINDINGS OF FACT 1. Recurrent subluxation or lateral instability of the left knee has manifested by no more than moderate instability of the left knee for the entire period of the claim. 2. For the entire rating period, the Veteran's service-connected status-post left patella fracture with arthritis and malunion of the patella manifested arthritis and pain on motion, but did not manifest flexion limited to 15 degrees, extension limited to 20 degrees, ankylosis, impairment of the tibia and fibula, or genu recurvatum. 3. The Veteran did not sustain a low back injury or disease in service. 4. The Veteran does not have a current low back disability. 5. The Veteran did not sustain a left wrist injury or disease in service. 6. Arthritis of left wrist did not manifest to a compensable degree within one year of separation from service. 7. The Veteran does not currently have arthritis or other disability of the left wrist. 8. In a July 2006 rating decision, the RO denied service connection for hypertension, finding that hypertension was not shown in service and that evidence did not show that hypertension is caused or aggravated by service-connected left knee and ankle disabilities. 9. The Veteran did not submit a timely notice of disagreement to the July 2006 rating decision. 10. The evidence received since the July 2006 rating decision denying service connection for hypertension is cumulative, does not relate to an unestablished fact necessary to substantiate the claim, and does not raise a reasonable probability of substantiating the claim. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for recurrent subluxation or lateral instability of the left knee have not been met for the entire rating period on appeal. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 5257 (2012). 2. The criteria for an evaluation in excess of 20 percent for status-post left patella fracture with arthritis and malunion of the patella have not been met for the entire rating period on appeal. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2012). 3. The criteria for service connection for low back disability have not been met. 38 U.S.C.A. §§ 1101, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 4. The criteria for service connection for arthritis of the left wrist have not been met. 38 U.S.C.A. §§ 1101, 1131, 1137, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 5. The July 2006 rating decision that denied service connection for hypertension is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2012). 6. New and material evidence has not been received to reopen service connection for hypertension. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353 -356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a claim for an increased rating, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Court has held that VCAA requires additional notice when a claimant seeks to reopen a previously denied claim. In Kent v. Nicholson, 20 Vet. Ap. 1, 9-10 (2006), the Court held that VA must examine the basis for a denial of a previously disallowed claim and provide the appellant with notice of the evidence of service connection found lacking in the previous denial. A May 2009 letter advised the Veteran of the evidence required to substantiate the claim for service connection for a low back condition. A November 2009 letter informed the Veteran of the evidence required to substantiate the claim for service connection for arthritis of the wrists and claim to reopen service connection for hypertension The November 2009 letter informed the Veteran of the basis of the prior denial of service connection for hypertension (not caused or related to service-connected fracture of the left patella or left ankle condition). The May 2009 and November 2009 letters advised the Veteran of VA's duties to assist him in obtaining evidence. The May 2009 and November 2009 letters included notice of how disability ratings and effective dates are determined. The May 2009 letter also provided the notice required by Vazquez, regarding the claim for an increased rating for the left knee disabilities. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. The information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, and the Veteran's statements. The Veteran was afforded a VA examination of his left knee in September 2009 and June 2011. The Veteran was afforded a VA examination of his low back in January 2011. The September 2009 and June 2011 examinations considered all the pertinent evidence of record, the Veteran's statements and history, and review of the claims file and provided a clinical examination of the Veteran's knee, which addressed the Veteran's symptoms, range of motion of the knee, and DeLuca factors, including pain, weakness, stiffness, and incoordination. The January 2011 VA examiner provided a medical opinion regarding the claimed low back disability based upon a review of all of the pertinent evidence of record, to include service treatment records and post-service VA medical records, and the Veteran's reported history of low back symptoms. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Veteran was not afforded a VA examination for a left wrist disability. The Board finds that a VA examination is not necessary to decide that claim, as the standards of the Court's decision in McLendon v. Nicholson, 20 Vet. App. 79 (2006), have not been met. Under McLendon, VA must provide a medical examination in a service connection claim when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Id. at 81. A VA examination is not necessary to decide the claim for service connection for a left wrist disorder (claimed as arthritis of the left wrist). The weight of the evidence demonstrates that the Veteran did not sustain a left wrist injury or disease in service, or otherwise show in-service symptoms of a left wrist disorder. There is competent medical evidence on file for VA to decide this issue. The weight of the competent evidence of record is against a finding of a current disability of the left wrist. The medical records reviewed, including post-service VA outpatient treatment and private treatment records, do not show any complaints, findings, or diagnoses of a left wrist disability. A VA examination is not required as there is no reasonable possibility that a VA examination or opinion could aid in substantiating the current claim for service connection. See 38 U.S.C.A. § 5103A(d). See also Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (holding that where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). The Veteran was afforded a VA examination in connection with his claim to reopen service connection for hypertension; however, the duty to provide a medical examination and/or obtain a medical opinion in a claim for disability compensation benefits does not apply in cases involving an attempt to reopen a finally adjudicated claim unless new and material evidence is presented or secured. See 38 C.F.R. § 3.159(c)(4)(iii). For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Disability Ratings - Law and Regulations Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating was filed until the final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). It should also be noted that, when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. 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. 38 C.F.R. § 4.40; DeLuca, 8 Vet. App. at 205. 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 innervation, or other pathology, or it may be due to pain, supported by adequate pathology or evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. The factors involved in evaluating, and rating disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. The Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Disability Rating Criteria for Knee Disabilities The Diagnostic Codes (DCs) that are potentially relevant to this case are 5003, 5257, 5260, and 5261. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings is to be evaluated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, an evaluation of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is assignable for x-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups. A 20 percent evaluation is assignable for x-ray evidence of involvement of arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. 38 C.F.R. § 4.71a. DC 5257 pertains to recurrent subluxation or instability of the knee. A 10 percent rating is assignable for slight recurrent subluxation or instability. A 20 percent rating is assignable for moderate recurrent subluxation or instability. A 30 percent rating is assignable for severe recurrent subluxation or instability. 38 C.F.R. § 4.71a. Diagnostic Code 5260 pertains to limitation of flexion. A 0 percent evaluation is assignable when flexion is limited to 60 degrees. A 10 percent evaluation is assignable when flexion is limited to 45 degrees. A 20 percent evaluation is assignable where flexion is limited to 30 degrees. An evaluation of 30 percent is assignable when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5261 applies to limitation of extension of the leg. A 0 percent evaluation is assignable for extension limited to 5 degrees. A 10 percent evaluation is assignable for extension limited to 10 degrees. A 20 percent evaluation is assignable for extension limited to 15 degrees. A 30 percent evaluation is assignable for extension limited to 20 degrees. A 40 percent evaluation is assignable for extension limited to 30 degrees. A 50 percent evaluation is assignable when extension is limited to 50 degrees. See 38 C.F.R. § 4.71a. Full range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2012). In VAOPGCPREC 23-97, the VA General Counsel interpreted that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating is based upon additional disability. Subsequently, in VAOPGCPREC 9-98, the VA General Counsel further explained that, if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. The General Counsel has also directed that separate ratings are available if a particular knee disability causes both the compensable (10 percent) limitation of extension (Diagnostic Code 6261) and compensable limitation of flexion (Diagnostic Code 6260) of the same joint. Specifically, where a veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04. Increased Rating for Recurrent Subluxation or Lateral Instability of the Left Knee A March 2006 rating decision implemented a March 2006 Board decision granting service connection for recurrent subluxation or lateral instability of the left knee. A 20 percent rating was assigned from September 2005, pursuant to Diagnostic Code 5257, which reflects moderate subluxation or instability. A claim for an increased rating was received in April 2009. The Veteran seeks an increased rating for recurrent subluxation or lateral instability of his left knee. In a written statement dated in January 2013, the Veteran indicated that his knee is unstable and has gotten worse. After a review of all the evidence, the Board finds that, for the entire rating period, recurrent subluxation or lateral instability of the left knee was no more than moderate, which warrants a 20 percent disability rating under Diagnostic Code 5257. The Veteran had a VA examination in September 2009. The Veteran reported a history of patella fracture in 1987. He reported that his symptoms were progressively worse since onset. The VA examiner indicated that examination findings showed no instability of the left knee. Upon VA examination in June 2011, the Veteran reported giving way of the left knee. He denied instability. The Veteran denied the use of assistive devices. The Veteran denied episodes of dislocation or subluxation. After reviewing the lay and medical evidence relevant to the rating period on appeal, the Board finds that the weight of the evidence is against a grant of a rating in excess of 20 percent for lateral instability of the left knee. The Veteran's left knee instability has not been characterized as severe at any point in the rating period. The September 2009 VA examination indicates that the VA examiner found that there was no instability of the left knee. Upon VA examination in 2011, the Veteran reported giving way, but denied instability. Based on this evidence, the Board finds that for the entire rating period on appeal, the Veteran's lateral instability of the left knee has been not more than moderate. Accordingly, a rating in excess of 20 percent is not warranted for left knee instability under Diagnostic Code 5257 for any period. 38 C.F.R. § 4.71a. For these reasons, the Board finds that the weight of the evidence is against the assignment of a rating in excess of 20 percent for any period for recurrent subluxation or lateral instability of the left knee. As there is a preponderance of the evidence against the appeal for a higher rating in excess of 20 percent for recurrent subluxation or lateral instability of the left knee, the appeal must be denied, and there remains no reasonable doubt to be resolved in the Veteran' favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Increased Rating for Status-post Left Patella Fracture with Arthritis and Malunion of the Patella An August 1989 rating decision granted service connection for status post left patella fracture with chondromalacia and malunion of the patella. A 20 percent rating was assigned from July 1989. A 20 percent rating is in effect for status-post left patella fracture, pursuant to Diagnostic Code 5260. A claim for an increased rating for status post left patella fracture with chondromalacia and malunion of the patella and recurrent subluxation or lateral instability of the left knee was received in April 2009. The Veteran contends that his left knee pain has worsened. He alleges that he can only walk or stand for short periods of time and cannot enjoy normal activities because of pain and arthritis. After a review of all the evidence, the Board finds that, for the entire rating period, the Veteran's service-connected left patella fracture with chondromalacia and malunion of the patella manifested arthritis and pain on motion, but did not manifest flexion limited to 15 degrees, extension limited to 20 degrees, left knee ankylosis, impairment of the tibia and fibula, or genu recurvatum. Such findings are consistent with a rating of not more than 20 percent under any Diagnostic Code. Upon VA examination in September 2009, the Veteran reported knee pain. He denied a history of trauma to the bones, bone neoplasm, osteomyelitis, or inflammation. He denied a history of deformity. The Veteran indicated that he did not use assistive devices. The Veteran reported that his knee condition affected motion of the joint. The Veteran denied flare-ups of joint disease. On physical examination in September 2009, the Veteran's gait was normal. The Veteran had flexion of the left knee from 10 to 80 degrees. Extension of the left knee was normal. The VA examiner indicated that there was no evidence of genu recurvatum. There was no objective evidence of pain following repetitive motion and no additional limitations after three repetitions of range of motion. The Veteran had a VA examination in June 2011. The Veteran reported pain, stiffness, weakness, and decreased speed of joint motion. The Veteran reported that symptoms of inflammation included tenderness. On physical examination in June 2011, the VA examiner indicated that the Veteran's gait was normal. The Veteran had flexion of the left knee to 80 degrees. The Veteran had normal extension to 0 degrees. The VA examiner indicated that there was objective evidence of pain following repetitive motion. The VA examiner indicated that there was no additional limitation after three repetitions of range of motion. A report of an x-ray of the left knee dated in June 2011 reflects that a physician diagnosed post-traumatic and post-surgical changes of the left patella, mild tricompartmental degenerative changes of the left knee, and slight progression of tricompartmental joint space narrowing since September 2009. The Board finds that, based on all of the evidence, the Veteran's left knee status-post left patella fracture with arthritis and malunion of the patella does not more nearly approximate the criteria for a rating in excess of 20 percent for any period. During the entire rating period, the Veteran's left knee manifested pain on motion, but, even with consideration of additional limitation of motion due to pain, it did not manifest flexion limited to 15 degrees, extension limited to 20 degrees, ankylosis, impairment of the tibia and fibula, or genu recurvatum. The Board has considered whether a separate rating is assignable for limitation of extension. However, as the Veteran has not had compensable limitation of extension, which is limitation of extension to 10 degrees, during the appeal period, a separate rating is not assignable for limitation of extension. See VAOPGCPREC 9-04. The Board has considered whether a higher rating is warranted based upon additional limitation of motion due to orthopedic factors, such as pain, guarding of movement, and fatigability. See DeLuca, supra.; 38 C.F.R. §§ 4.45, 4.59. The September 2009 VA examination indicated that there was no objective evidence of pain with active motion on the left side. The June 2011 VA examination indicated that the Veteran had flexion of the left knee to 80 degrees. There was objective evidence of pain with motion, but there was no indication that that flexion of the left knee was limited to 15 degrees due to pain. The VA examinations in September 2009 and June 2011 indicated that there was no additional limitation of motion of the left knee with repetitive use. The Board acknowledges that the VA examination in June 2011 showed pain in the left knee with active motion. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance, in order to constitute functional loss. Id. at 11; see also 38 C.F.R. § 4.40. The evidence in this case does not show additional functional loss or limitation of motion of the left knee due to such factors as pain to more nearly approximate the criteria for a higher disability rating than 20 percent, or separate compensation limitation of extension, based upon limitation of motion. A higher rating is not warranted under Diagnostic Code 5256, as ankylosis of the left knee is not shown. A higher rating is not assignable under Diagnostic Codes 5262 or 5263, as the evidence does not show impairment of the tibia and fibula or genu recurvatum. For these reasons, the Board finds that the weight of the evidence is against the assignment of a rating in excess of 20 percent for any period for status-post left patella fracture with arthritis and malunion of the patella. As there is a preponderance of the evidence against the appeal for a higher rating in excess of 20 percent for status post left patella fracture with arthritis and malunion of the patella, the appeal must be denied, and there remains no reasonable doubt to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7 Extraschedular Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, the Board finds that the schedular rating criteria contemplate all the impairments associated with the Veteran's knee disabilities. The rating criteria pertaining to the Veteran's service-connected knee disabilities consider the range of motion of the knee. The schedular rating criteria for the knee disabilities also consider limitation of motion of the knee, including due to arthritis, pain, and other orthopedic factors that are incorporated into the schedular rating criteria. 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca. The schedular rating criteria provide for separate schedular ratings based on the severity of subluxation or instability. Because the schedular rating criteria are adequate to rate the Veteran's knee disabilities, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship of nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In this case, arthritis is a "chronic disease" listed under 38 C.F.R. § 3.309(a). However, a diagnosis of arthritis of the wrists or low back has not been shown. Therefore, § 3.303(b) does not apply to the claim for service connection for arthritis of the bilateral wrists. Low back or wrist pain is not a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply to the claim for service connection for low back pain. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). In rendering a decision on appeal the Board must also 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. 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. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility 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"). Service Connection for Low Back Pain The Veteran asserts that he currently has pain and arthritis of the low back, which is either caused or aggravated by service-connected left knee or ankle disabilities. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not sustain an injury or disease of the low back in service. The report of the December 1983 enlistment examination reflects that clinical evaluation of the spine was normal. Service treatment records do not reflect any complaints, findings, or diagnoses regarding the low back. The Veteran denied a back injury upon VA examination in January 2011. The Veteran separated from service in July 1989. He did not undergo a service separation examination. The Board finds that the weight of the evidence demonstrates that there is no current disability of the low back. Upon VA examination in January 2011, the Veteran reported that he had developed low back pain and was unsure why. He denied an injury to his back. The Veteran reported that he spoke with a provider who told him that he may have arthritis in his back since he has it in his knees and left ankle. The Veteran reported that he felt his back was getting worse. An x-ray of the lumbar spine in January 2011 showed no significant abnormality. The VA examiner diagnosed lumbar arthralgia. The January 2011 VA examiner opined that lumbar arthralgia is not caused by or a result of the Veteran's service-connected left knee and left ankle disabilities. The VA examiner reasoned that, considering that the Veteran is ambulating normally and has equal hip/ shoulder height, it is doubtful that his low back pain is secondary to his left knee and ankle pain. Arthralgia is defined as "pain in a joint." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (30th Ed. 2003). The Board observes that an assessment of pain is not an assessment of a disability. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (holding that "pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted"). In this case, although the Veteran has asserted that he has arthritis, he has not been diagnosed with arthritis of his low back. While the Veteran is competent to report symptoms that he has experienced in his low back, such as pain, the matter of a diagnosis of arthritis and the etiology of a diagnosed disorder of the low back requires medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed.Cir. 2007). Thus, as a lay person, the Veteran is not competent to diagnose arthritis or offer an opinion on medical causation, as an opinion regarding the relationship between the left knee, left ankle, and low back disabilities requires expertise regarding the musculoskeletal system. The Board finds that the weight of the evidence demonstrates that a current low back disorder is not caused or aggravated by service-connected disabilities. The January 2011 VA medical opinion concluded that lumbar arthralgia is not caused by or a result of the Veteran's service-connected left knee and left ankle disabilities. Based upon the foregoing, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a current low back disability. A present disability is a prerequisite to the granting of service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, service connection for the claimed low back disability must be denied. Id. Therefore, the Board finds that the preponderance of the evidence is against the claim for service connection for low back pain. As there is a preponderance of the evidence against the appeal for service connection for a low back disability, there remains no reasonable doubt to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Arthritis of the Left Wrist After a review of the evidence, the Board finds that the Veteran did not sustain an injury of the left wrist during service. The Veteran did not report any injury of the left wrist in service, and service treatment records do not reflect that any disability of the left wrist was noted. Service treatment records show that the Veteran received treatment for his left hand in March 1987; however, there were no complaints or findings regarding the left wrist. The Board finds that the evidence demonstrates that there is no current disability of the left wrist. Post-service VA and private medical records in evidence do not reflect any diagnoses or treatment of a left wrist disability, including arthritis of the left wrist. Lay evidence may establish the existence of a current disorder capable of lay observation, to include such conditions as varicose veins, tinnitus, and flat feet. Barr v. Nicholson, 21 Vet. App. 303 (2007); Charles v. Principi, 16 Vet. App. 370, 374 (2002); Falzone v. Brown, 8 Vet. App. 398, 405 (1995); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology). Pursuant to the foregoing, the Board does not find competent any assertions of the Veteran that he has arthritis of the left wrist because, unlike varicose veins, tinnitus, and flat feet, arthritis it is not the sort of medical condition that is capable of lay observation. Arthritis is not visible and requires an x-ray or similar study and skilled interpretation of the x-ray for diagnosis. As well, arthritis is not diagnosed based on symptoms of pain alone, of which the Veteran is competent to observe and state, but its presence is based on radiologic findings or other clinical testing. Jandreau, supra. Based upon the foregoing, the Board finds that the weight of the evidence is against service connection for arthritis of the left wrist. A present disability, in this case the claimed arthritis of the left wrist, is a prerequisite to the granting of service connection. See Brammer, supra. For the reasons set forth above, the Board finds that a preponderance of the evidence is against the claim for service connection for arthritis of the left wrist. As stated, there is no present disability of the left wrist. Because the preponderance of the evidence is against the claim, there remains no reasonable doubt to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Claim to Reopen Service Connection for Hypertension A July 2006 rating decision denied service connection for hypertension, as secondary to service-connected left knee and left ankle disabilities. The rating decision found that service treatment records did not show complaints or diagnoses of hypertension and that hypertension was not shown to be related to the Veteran's service-connected left knee and left ankle disabilities. The Veteran did not submit a timely NOD to the July 2006 rating decision, and it became final. 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. In April 2009, the Veteran sought to reopen service connection for hypertension. In general, if new and material evidence is presented or secured with respect to a finally adjudicated claim, VA shall reopen and review the claim. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decisionmakers. 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. 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). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Evidence is presumed to be credible for the purpose of determining whether the case should be reopened; once the case is reopened, the presumption as to the credibility no longer applies. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The evidence must be both new and material; if the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). If the Board determines that the evidence submitted is new and material, it must reopen the case and evaluate the appellant's claim in light of all the evidence. Justus, 3 Vet. App. at 512. The evidence of record at the time of the July 2006 rating decision included service treatment records, post-service VA treatment records, and a report of a VA examination dated in June 2006. Service treatment records do not reflect any diagnoses of hypertension. The VA examination report dated in June 2006 reflects that a VA examiner diagnosed hypertension. The VA examiner opined that, based upon a review of the Veteran's medical records, hypertension was not caused by his patella fracture. The VA examiner explained that there is no known link between these acute events and chronic medical conditions such as high blood pressure. The VA examiner opined that, for the same reason, the Veteran's knee condition does not aggravate his hypertension. The evidence received since the July 2006 rating decision includes lay statements submitted by the Veteran, private medical records, and a report of a VA examination dated in May 2012. VA treatment records reflect treatment for hypertension but do not provide any medical evidence linking hypertension to service or to a service-connected disability. A report of a VA examination dated in May 2012 reflects that the VA examiner opined that hypertension is not caused or aggravated by diabetes mellitus. The negative opinion is not material, as it does not "raise a reasonable probability of substantiating the claim." 38 C.F.R. § 3.156(a). The Veteran's written statements reflect his contention that hypertension is related to his service-connected left knee and left ankle disabilities. He asserts that he cannot exercise because of his service-connected disabilities, which makes it difficult to control his blood pressure. The Board finds that the VA treatment records, private medical records, and report of VA examination dated in May 2012 are new, as they were not previously of record; however, they are not material. The VA treatment records and private medical records reflect current treatment of hypertension, but they do not provide competent medical evidence that hypertension is proximately due to, or aggravated by, the Veteran's service-connected left knee and left ankle disabilities. The May 2012 VA examination reflects the examiner's opinion that hypertension is not caused or aggravated by service-connected diabetes mellitus. Therefore, the May 2012 VA examination is not material. The Veteran's statements regarding a relationship between his left knee and left ankle disabilities and his hypertension are not new evidence. The Veteran's statements reflect a new theory of causation regarding secondary service connection. The Veteran's assertions that hypertension is related to service-connected left knee and left ankle disabilities are not new evidence, as these assertions have been previously rejected. See Moray v. Brown, 5 Vet. App. 211 (1993) (lay assertions of medical causation cannot serve as the predicate to reopen a claim under 38 U.S.C.A. § 5108). For these reasons, the Board finds that newly received evidence does not raise a reasonable possibility of substantiating the claim. Accordingly, the evidence received since the July 2006 rating decision is not new and material, and reopening of service connection for hypertension is not warranted. Because the new evidence, in the context of all the evidence of record, has not fulfilled the burden of being new and material evidence to reopen the finally disallowed claim, the benefit-of-the-doubt doctrine is not applicable and the claim remains denied. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993); see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER A disability rating in excess of 20 percent for recurrent subluxation or lateral instability of the left knee, for the entire rating period, is denied. A disability rating in excess of 20 percent for status-post left patella fracture with arthritis and malunion of the patella, for the entire rating period, is denied. Service connection for low back pain is denied. Service connection for a left wrist disorder, claimed as arthritis of the left wrist, is denied. New and material evidence not having been received, the appeal to reopen service connection for hypertension is denied. REMAND Additional development is warranted with regard to the Veteran's claims for service connection for diabetes mellitus and service connection for a right wrist disorder. The claim for service connection for erectile dysfunction is intertwined with the claim for service connection for diabetes mellitus; therefore, action on that claim is deferred. Service Connection for Diabetes Mellitus The Veteran claims service connection for diabetes mellitus secondary to service-connected left knee and left ankle disabilities. The Veteran asserts that his left knee and left ankle disabilities prevent him from exercising, and have, therefore, aggravated diabetes mellitus. In June 2011, a VA examiner opined that it is at least as likely as not that the Veteran's inability to exercise to control blood sugars is aggravated by, or a result of, his service-connected status post left patella fracture with chondromalacia and mal-union of the patella, recurrent subluxation or lateral instability of the left knee, and left ankle pain. The VA examiner indicated that his opinion was based upon a careful review of the records and the Veteran and consideration of similar cases in medical textbooks. The opinion did not explain why the service-connected disabilities of the left knee and left ankle precluded all exercise and physical activity and also did not explain why impairment of the left knee and left ankle cause obesity. The VA examiner did not explain the relevance of medical textbooks to the determination and did not address what records were reviewed that showed that the Veteran could not perform any exercise or physical activity, including exercises involving the other three extremities, hips, torso, and neck, and non weight-bearing exercises. The VA examiner also did not establish a baseline from which an opinion of aggravation could be derived. For these reasons, the June 2011 VA examination opinion is inadequate. In May 2012, a VA examiner opined that it is less likely than not that the Veteran's service-connected left knee and left ankle conditions aggravated diabetes mellitus. The VA examiner indicated that this opinion was based upon careful examination of the provided records and the Veteran, with relation to considered conditions and similar cases in medical textbooks. In November 2012, the RO requested that a physician review the claims file and provide an opinion to reconcile the conflicting June 2011 and May 2012 medical opinions. The reviewing physician opined that the medical literature is clear that glycemic control (and therefore the severity of the individual's diabetes) can be improved with exercise. The VA examiner reasoned that exercise alone improves glycemic control, and the addition of weight loss as a potential result of exercise further improves glycemic control. The VA examiner opined that it is more likely than not that the Veteran's diabetes was aggravated beyond its natural progression by the Veteran's service-connected left knee condition and left ankle pain. The VA examiner reasoned that both of these conditions limit the Veteran's ability to exercise based on the examination findings documented in June 2011; however, the VA examiner indicated that he was unable to establish baseline manifestations of diabetes mellitus because of insufficient medical evidence. The VA examiner's opinion is inadequate, as it did not provide a finding regarding the baseline manifestation of diabetes mellitus. In this case, the November 2012 VA examiner opined that the Veteran's service-connected left knee and left ankle disabilities result in an inability to exercise, thus aggravating diabetes mellitus; however, the VA examiner did not discuss what types of exercise are possible for the Veteran, using the other three extremities, torso, neck, hips or non weight-bearing exercises or discuss the abilities or inabilities of these, and any non service-connected impairments or whether the Veteran had full use of the rest of his body. The examiner also did not address whether, in his medical opinion, the service-connected left knee and left ankle disabilities prevent all forms of exercise. The Board finds that a remand is warranted in order for the VA examiner to try to provide an adequate addendum opinion that addresses these inadequacies and provides a baseline for any opinion. Service Connection for a Right Wrist Disorder With regard to the right wrist, the Veteran was treated for a right wrist injury during service. In October 1984, the Veteran was seen in sick call with a complaint that he slipped coming out of the chow hall. Examination of the right wrist showed slight erythema. There was no cyanosis, drainage, swelling, or edema. Assessment was minor abrasion of the right wrist. The Veteran asserts that he currently has wrist pain. The Veteran has not been afforded a VA examination of his right wrist. In light of the in-service injury and the Veteran's current report of right wrist pain, a VA examination is necessary to assist in determining whether there is a right wrist disability and, if so, whether any current disability is related to the in-service abrasion of the right wrist. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Service Connection for Erectile Dysfunction Finally, the Board finds the claim for service connection for erectile dysfunction to be inextricably intertwined with the claim for service connection for diabetes, as there is some indication that this disability may be associated with diabetes mellitus. A September 2009 VA examination indicated that erectile dysfunction is causally related to diabetes mellitus. Harris v. Derwinski, 1 Vet. App. 180 (1991) (when a determination on one issue could have a significant impact on the outcome of another issue, such issues are considered inextricably intertwined and VA is required to decide those issues together). As such, the claim for service connection for erectile dysfunction should not be decided until the service connection claim for diabetes has been resolved. Accordingly, the issues of entitlement to service connection for diabetes mellitus, a right wrist disorder, and erectile dysfunction are REMANDED for the following action: 1. Return the claims file to the physician who provided the November 2012 VA medical opinion regarding the issue of entitlement to service connection for diabetes mellitus. 2. The VA examiner is requested to elaborate on his opinion that the Veteran's service-connected left knee and left ankle disabilities cause an inability to exercise, thereby aggravating diabetes mellitus. a. The VA examiner should address whether the Veteran's left knee and left ankle disabilities prevent the Veteran from doing any type of exercise which would improve glycemic control. The VA examiner should explain why all forms of exercise are precluded. The VA examiner should specifically address whether the Veteran can do any forms of exercise, e.g. exercise in a pool. The VA examiner should also state why the Veteran cannot perform any exercise using the rest of his body other than his left knee and left ankle. If the examiner opines that diabetes mellitus is aggravated by the service-connected left knee and left ankle disabilities, the examiner must report the baseline level of severity of the nonservice-connected diabetes mellitus prior to the onset of aggravation. If some of the increase in severity of the nonservice-connected disability is due to the natural progress of the disease, the examiner should indicate the degree of such increase in severity due to the natural progression of the disease. An opinion that does not address the baseline severity of diabetes prior to purported aggravation is inadequate. The VA examiner should provide a detailed rationale for any opinions expressed. 3. If, and only if, the November 2012 VA examiner is not available, schedule the Veteran for an examination with regard to his claim for service connection for diabetes mellitus. The claims file should be provided for the examiner's review, and the examiner should indicate in the examination report that the claims file was reviewed. a. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater likelihood) that current diabetes mellitus is proximately caused by, or due to, service-connected left ankle and left knee disabilities. b. The examiner should provide an opinion as to whether current diabetes mellitus is aggravated by service-connected left ankle and left knee disabilities. If examiner opines that diabetes mellitus is aggravated by service-connected left ankle and left knee disabilities, the examiner must report the baseline level of severity of the nonservice-connected diabetes mellitus prior to the onset of aggravation. If some of the increase in severity of the nonservice-connected disability is due to the natural progress of the disease, the examiner should indicate the degree of such increase in severity due to the natural progression of the disease. An opinion that does not address the baseline severity of diabetes prior to purported aggravation is inadequate c. In providing this opinion, the VA examiner should consider and address the Veteran's contention that he is unable to exercise because of his service-connected left knee and left ankle disabilities. The VA examiner should address whether the Veteran's left knee and left ankle disabilities prevent the Veteran from doing any type of exercise which would improve glycemic control. The VA examiner should explain why all forms of exercise are precluded. The VA examiner should specifically address whether the Veteran can do any forms of exercise, e.g., exercise in a pool. The VA examiner should also state why the Veteran cannot perform exercise using the rest of his body other than his left knee and left ankle. The VA examiner should provide a detailed rationale for any opinions expressed. 4. Schedule the Veteran for a VA examination of his right wrist. The relevant documents in the claims file should be provided for the examiner's review, and the examination report should indicate that the claims file was reviewed. The VA examiner should provide an opinion as to whether a current right wrist disability is at least as likely as not (50 percent or greater likelihood) related to service, including the minor abrasion injury in service in October 1984. The examiner should provide a detailed rationale for the opinion expressed. 5. Re-adjudicate the issues on appeal. If the benefits sought remain denied, the Veteran should be furnished with a supplemental statement of the case and be afforded an opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the 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. 2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs