Citation Nr: 1317684 Decision Date: 05/30/13 Archive Date: 06/06/13 DOCKET NO. 10-22 632 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for an acquired psychiatric disorder, not including PTSD, to include anxiety, cognitive disorder NOS, depressive disorder NOS, depressive neurotic reaction and major depression recurrent with psychotic features, claimed as secondary to a service-connected right elbow disability. 3. Entitlement to service connection for intervertebral disc herniation of T11 to T12 level and L1 to L3, L5, and S1 (back disability), claimed as secondary to a service-connected right elbow disability. 4. Entitlement to service connection for a left ankle disorder, claimed as secondary to a service-connected right elbow disability. 5. Entitlement to service connection for a right ankle disorder, claimed as secondary to a service-connected right elbow disability. 6. Entitlement to service connection for a left knee disorder, claimed as secondary to a service-connected right elbow disability. 7. Entitlement to service connection for a right knee disorder, claimed as secondary to a service-connected right elbow disability. 8. Entitlement to service connection for a left shoulder disorder, claimed as secondary to a service-connected right elbow disability. 9. Entitlement to a disability evaluation in excess of 10 percent for the service-connected status-post trauma to right distal humerus, old avulsion fracture of the styloid process of ulna (hereinafter referred to as a "right elbow disability"). 10. Entitlement to total disability evaluation based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.M. Rutkin, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1958 to March 1960, with confirmed service in Korea from November 1958 to December 1959. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico (San Juan). The Veteran requested a hearing before a Decision Review Officer (DRO) in his May 2010 substantive appeal (VA Form 9). However, he cancelled his hearing request in an August 2010 statement. Thus, the hearing request is deemed withdrawn. See 38 C.F.R. § 20.704 (2012). In January 2013 the Board remanded these claims for further development. After completion of this development by the Appeals Management Center (AMC), the case has been returned to the Board for further appellate consideration. A review of the Virtual VA paperless claims processing system reveals additional VA treatment records which were considered by the AMC as agency of original jurisdiction (AOJ) in an April 2013 Supplemental Statement of the Case (SSOC). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The service connection claim for PTSD and/or an acquired psychiatric disorder, not including PTSD, to include anxiety, cognitive disorder NOS, depressive disorder NOS, depressive neurotic reaction and major depression recurrent with psychotic features; and the issue of 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. A back disability was not caused or aggravated by a service-connected right elbow disability, and is not related to any disease, injury, or event during active service. 2. A left ankle disorder was not caused or aggravated by a service-connected right elbow disability, and is not related to any disease, injury, or event during active service. 3. A right ankle disorder was not caused or aggravated by a service-connected right elbow disability, and is not related to any disease, injury, or event during active service. 4. A left knee disorder was not caused or aggravated by a service-connected right elbow disability, and is not related to any disease, injury, or event during active service. 5. A right knee disorder was not caused or aggravated by a service-connected right elbow disability, and is not related to any disease, injury, or event during active service. 6. A left shoulder disorder was not caused or aggravated by a service-connected right elbow disability, and is not related to any disease, injury, or event during active service. 7. The Veteran's right elbow disability is manifested by a marked cubitus varus or cubitus valgus deformity, pronation limited to 30 degrees or less, limited flexion exceeding 110 degrees, and extension to 0 degrees, with chronic pain. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection on a direct or secondary basis for a back disability have not been satisfied. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 2. The criteria for entitlement to service connection on a direct or secondary basis for a left ankle disorder have not been satisfied. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 3. The criteria for entitlement to service connection on a direct or secondary basis for a right ankle disorder have not been satisfied. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 4. The criteria for entitlement to service connection on a direct or secondary basis for a left knee disorder have not been satisfied. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 5. The criteria for entitlement to service connection on a direct or secondary basis for a right knee disorder have not been satisfied. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 6. The criteria for entitlement to service connection on a direct or secondary basis for a left shoulder disorder have not been satisfied. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 7. The criteria for a separate rating of 20 percent for marked cubitus valgus or cubitus varus deformity have been satisfied throughout the pendency of this appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 3.102, 4.3, 4.71a, Diagnostic Code 5209 (2012). 8. The criteria for a separate rating of 10 percent for limitation of pronation of the right arm to 30 degrees or less have been satisfied throughout the pendency of this appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 3.102, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5213 (2012). 9. The criteria for a rating in excess of 10 percent for painful and limited flexion and extension of the right elbow have not been satisfied. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 3.102, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5206, 5207 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Introductory Matters In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the United States Court of Appeals for the Federal Circuit (Federal Circuit) (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (Court) (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d) (West 2002); see also 38 C.F.R. § 19.7 (2012) (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). II. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002), sets forth VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In order to satisfy its duty to notify the claimant under the VCAA, the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and 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, 187 (2002). All notice under the VCAA should generally be provided prior to an initial decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, a delay in timing of the notice is "cured," and therefore harmless, when a fully compliant VCAA notification letter is followed by readjudication of the claim (such as through issuing a statement of the case or supplemental statement of the case) after the claimant has had an opportunity to submit additional evidence. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). A claim of entitlement to service connection consists of five elements: (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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006). The Court has held that notification of what evidence is necessary to substantiate the claim under 38 U.S.C.A. § 5103(a) requires notice of these five elements. See id. at 486; Quartuccio, 16 Vet. App. at 187. Prior to the initial rating decision in this matter, a September 2006 letter informed the Veteran of all five elements of service connection, gave examples of the types of evidence the Veteran could submit in support of his claims, and provided notice of the Veteran's and VA's respective responsibilities for obtaining relevant records and other evidence on his behalf. A March 2009 letter also provided all required notice under the VCAA, and additionally notified the Veteran of the elements of service connection on a secondary basis. Although this letter was not sent prior to initial adjudication of the Veteran's claims, the delay was harmless as the Veteran had an opportunity to respond with additional information and evidence before his claim was readjudicated in an April 2010 statement of the case (SOC) and several supplemental SOC's (SSOC's). See Mayfield, 499 F.3d at 1323. Therefore, the duty to notify has been satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Dingess/Hartman, 19 Vet. App. at 484; Quartuccio, 16 Vet. App. at 187. VA's duty to assist under the VCAA includes helping the claimant to obtain service treatment records and other pertinent records, as well as providing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's service treatment records and VA medical records are in the file. Private medical records identified by the Veteran have been obtained to the extent possible. In response to a January 2013 letter requesting him to identify any additional relevant treatment records, the Veteran submitted an authorized release form (VA Form 21-4142) for Fondo Seguro Estado (FSE), but did not provide an address or a signature. He was notified of the missing information and signature in a March 2013 letter and he was asked to resubmit the completed form. He responded by submitting a March 2013 statement on the same form indicating that these records were "inactive" and that he wished to have his claims addressed based on the evidence of record. Thus, efforts to obtain the Veteran's treatment records from FSE are not warranted. He has not identified any other outstanding records. Accordingly, the duty to assist has been satisfied with respect to obtaining relevant records on the Veteran's behalf. See 38 C.F.R. § 3.159(c). The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). With regard to increased rating claims, where the evidence of record does not reflect the current state of the veteran's disability, a new VA examination must generally be conducted. See 38 C.F.R. § 3.327(a); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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). However, unless the record indicates, or the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate, and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Id. The Veteran was provided appropriate VA examinations addressing all his claimed disabilities in March 2013. The VA examination reports are adequate for the purpose of deciding these claims. The examiners reviewed the claims file and medical history, conducted examinations of the Veteran and recorded the clinical findings, and provided clear explanations for the opinions stated which are consistent with the examiners' findings and the credible evidence of record. See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion" even when the rationale does not explicitly "lay out the examiner's journey from the facts to a conclusion" ) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)); see also D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). There are no significant inconsistencies or ambiguities in the examination reports, and the Veteran has not challenged their adequacy or thoroughness, or the competency of the examiners. See Sickels, 643 F.3d at 1365-66; Rizzo, 580 F.3d at 1290-1291. Accordingly, VA's duty to assist with respect to obtaining a VA examination has been met. See 38 C.F.R. §§ 3.159(c)(4); 3.326(a); McLendon, 20 Vet. App. at 83; Barr, 21 Vet. App. at 312. In the VA examination reports addressing the Veteran's back disability, bilateral ankle disabilities, and shoulder disability, the examiner opined that that the disability in question was not "secondary to" the right elbow fracture because the back, ankles, and shoulder were "not anatomically related." Although the examiner did not specifically state that the Veteran's back disability, bilateral ankle disabilities, and shoulder disability were not aggravated by the right elbow disability, it is clearly apparent from the examiner's explanation that the phrase "secondary to" contemplated both causation and aggravation relative to the right elbow disability. The examiner stated that these areas were "not anatomically related" to the right elbow, and it thus follows that since the examiner's conclusion was based on her finding that there was no anatomical relationship between the right elbow and the affected joints or limbs in question , then it would be physically impossible for the elbow disability to aggravate the other claimed orthopedic disabilities. Significantly, in the opinion addressing the Veteran's knee disorders, the examiner offered the same explanation, namely that the knees were not anatomically related to the right elbow, and also specified that the elbow disability did not aggravate the knee disorders. Thus, although the examiner (most likely inadvertently) omitted the word "aggravation" from the opinions addressing the other claimed orthopedic disorders, these opinions no doubt also contemplated the aggravation component, as they are based on the same rationale supporting the bilateral knee opinion, and there is indication that these other disorders would warrant a different analysis regarding the issue of aggravation than that which was applied to the knee disorders. These opinions are thus distinguishable from that found inadequate in El-Amin v. Shinseki, 26 Vet. App. 136 (2013). In that case, the Court held that a VA examiner's finding that the disability in question was caused by factors other than a service-connected disability did not address the issue of whether the claimed disability was nevertheless aggravated by the service-connected disability, irrespective of whether there was a causal relationship. However, unlike the examiner's opinion in El-Amin, the March 2013 VA examiner's opinion was not based primarily on the fact that the claimed orthopedic disability was caused by other factors; rather the examiner directly addressed the issue of whether it could be aggravated by the service-connected disability in stating that there was no anatomic relationship between the claimed disability and the service-connected disability. Implicit in this finding is that there could be no relationship whatsoever between the disabilities, either by way of causation or aggravation. Moreover, the examiner's phrase "secondary to" would encompass both causation and aggravation, to the extent that phrase was used in the same sense as used in the regulations. See 38 C.F.R. § 3.310. Thus, although the examiner did not use the word "aggravation" or similar language, the examiner's findings clearly addressed both the issue of causation and the issue of aggravation. See Monzingo, 26 Vet. App. at 107; Acevedo, 25 Vet. App. at 293. With regard to the issue of direct service connection, the examiner did not explicitly state a finding that the bilateral ankle and knee disorders, and left shoulder disorder, were not incurred in or aggravated by active service. Nevertheless, the examiner's opinion that these disorders were most likely due to the aging process by necessity indicates that they are not related to active service, which occurred when the Veteran was a younger man. Moreover, as the Veteran has not stated and there is no evidence showing that these disorders manifested during service or for decades following service separation, or that he had any in-service injuries relevant to the incurrence or aggravation of these disorders, there is no indication that they may be related to service. Thus, further opinion on this issue is not warranted. See McLendon, 20 Vet. App. at 83 (holding, in relevant part, that the duty to provide a VA examination or opinion is triggered when there is an indication that a current disability may be related to an in-service disease, injury, or event). With regard to the increased rating claim for the right elbow disability, the Veteran has not stated and there is no other evidence indicating that there has been a material change in the severity of his right elbow disability since he was last examined in March 2013. See 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007); VAOPGCPREC 11-95 (April 7, 1995). Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4); Barr, 21 Vet. App. at 312. In sum, VA's duty to notify and assist under the VCAA has been satisfied. The Veteran has had ample opportunity to participate in the development of his claim. See Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011) (citing Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that any error depriving a claimant of "a meaningful opportunity to participate effectively in the processing of his or her claim . . . . must be considered prejudicial")). Any defect in the notice or assistance provided did not affect the outcome of this claim or compromise the "essential fairness of the adjudication," and no defect has been alleged. See Mayfield v. Nicholson, 19 Vet. App. 103, 116 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, any error in the notice or assistance provided was harmless, and no prejudice exists. See Shinseki v. Sanders 556 U.S. 396, 407, 410 (2009) (holding that the "rule of prejudicial error" requires a case-by-case determination as to whether the error in question was harmless, and that it is the burden of the claimant to show that the error was harmful by at least providing an explanation as to how the error caused harm); see also 38 U.S.C.A. § 7261(b)(2) (West 2002). Accordingly, the Board may proceed with appellate review. III. Procedural Due Process The Board remanded these claims in January 2013 for further development. In Stegall v. West, 11 Vet. App. 268, 271 (1998), the Court held that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Board's remand directives to send the Veteran a letter requesting him to identify additional treatment records, including any Worker's Compensation records, to associate outstanding VA treatment record with the claims file (such records were uploaded to Virtual VA), to provide appropriate VA examinations responsive to the Board's instructions, and then to readjudicate the claims in an SSOC have been satisfied, as shown in the above discussion addressing VA's duties to notify and assist the Veteran. Thus, there has been compliance with all of the Board's January 2013 remand directives. See id. IV. Service Connection The Board has thoroughly reviewed all the evidence in the claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. See id. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995) The standard of proof to be applied in decisions on claims for veterans' benefits is the benefit-of-the-doubt rule set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must weigh against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board must assess the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). This evaluation generally involves a three-step inquiry. First, the Board must determine whether the evidence is competent. See, e.g. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Second, the Board must determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). Third, the Board must assess the probative value and weight of the evidence in light of the entire record. Gonzales, 218 F.3d at 1380-81. As observed by the Federal Circuit, lay evidence must "demonstrate some competence." See King v. Shinseki, 700 F.3d, 1339, 1345 (Fed. Cir. 2012) (citing 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.307(b)) (internal quotation marks omitted). The Board may therefore discount the probative value of lay evidence if it finds such evidence not to be competent. See id. (affirming the Court's finding that the Board did not improperly discount the probative value of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration). However, the Board may not "categorically" require medical evidence or disregard lay evidence without first assessing its competence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (holding that it was error in a cause-of-death claim to find "categorically" that a medical opinion was required to prove a nexus between the Veteran's service-connected mental disorder and his drowning death, and likewise to reject categorically the claimant's testimony on this issue as not competent because she was a lay person); see also Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011) (holding that the Board erred in categorically rejecting lay evidence without analyzing and weighing it). Importantly, lay statements submitted by or on behalf of a claimant can be competent with respect to both the diagnosis and the etiology or cause of a disability. See Davidson, 581 F.3d at 1316. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. See 38 C.F.R. § 3.159(a)(2); Layno, 6 Vet. App. at 469 (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). Lay evidence is competent if it is provided by a person who has first-hand knowledge of facts or circumstances, or conveys matters that can be observed and described by a lay person. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that appellant was competent to testify as to factual matters of which he had first-hand knowledge, such as experiencing pain in his right hip and thigh in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy). For example, the Court has held that a lay person is competent to diagnose a disease with "unique and readily identifiable features" such as varicose veins. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Similarly, the Court has found a lay person competent to identify tinnitus and flat feet, which are disorders that can be identified based on lay observation alone. See Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). However, lay testimony is not competent with respect to determinations that are "medical in nature" or require medical knowledge due to their complexity. See Barr, 21 Vet. App. at 309. For example, the Court held that a claimant was not competent to determine whether he had rheumatic fever, which was a more medically complex condition. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Federal Circuit has held that lay evidence may be competent and sufficient to establish a diagnosis of a condition in the following circumstances: (1) when the condition is simple, such as a broken leg, as opposed to when the condition is more complex, such as a form of cancer; (2) when the layperson is reporting a contemporaneous medical diagnosis, or; (3) when lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372, 1377 & n4 (Fed. Cir. 2007). Competent medical evidence, as distinguished from lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Id. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. Id. The competency of evidence differs from the weight assigned to the evidence, which varies according to its credibility, probative value, and relationship to other items of evidence. See Layno, 6 Vet. App. at 469 (holding that the weight and credibility of testimony, as distinguished from its competency, is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted); accord Rucker v. Brown, 10 Vet. App. 67, 74 1997); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probity of evidence in the light of its own inherent characteristics in its relationship to other items of evidence"); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (stating that "although interest may affect the credibility of testimony, it does not affect competency to testify."); Washington, 19 Vet. App. at 368 (noting that the witness's credibility affects the weight to be given to his testimony). In determining whether statements submitted by a veteran are credible, the Board may consider their internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. at 711, aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). Further, the Federal Circuit has held that while the absence of contemporaneous medical records does not, in and of itself, render lay testimony not credible, the Board may weigh the absence of contemporaneous records when assessing the credibility of lay evidence. See Buchanan, 451 F.3d at 1336 ("Nor do we hold that the Board cannot weigh the absence of contemporaneous medical evidence against the lay evidence of record."). Moreover, although the Board cannot reject a claimant's statements merely because he is an interested party, the claimant's interest may affect the credibility of his testimony when considered in light of the other factors. See Cartright, 2 Vet. App. at 25; accord Buchanan, 451 F.3d at 1337 (holding that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias . . . ."). Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the Federal Circuit held that a three-element test must be satisfied in order to establish entitlement to service connection. Walker v. Shinseki, 708 F.3d 1331, 1333 (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Id. However, claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard under 38 C.F.R. § 3.303(b). See Walker, 708 F.3d at 1339 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases"). Specifically, when a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain in a claim for arthritis or abnormal heart action in a claim for heart disease) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The Federal Circuit noted that the requirement of showing a continuity of symptomatology after service under subsection 3.303(b) is a distinct and lesser evidentiary burden than the nexus element of the three-part test discussed above: "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added). Walker, 708 F.3d at 1338-1339. Thus, showing a continuity of symptomatology after service is an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation" for chronic diseases. Id. at 1338; see also id. at 1336 (observing that section 3.303(b) provides a "second route by which a veteran can establish service connection for a chronic disease"). A continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. at 1338. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the more relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. Thus, if the claimed disability is not one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "the 'nexus' requirement of the three-element test" must be satisfied in order to establish entitlement to service connection benefits. Id. For example, the Federal Circuit held in Walker that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as it found that the claimant's hearing loss was not among the chronic diseases listed in section 3.309(a)). Id. at 1336-37, 1340. Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service connected disease or injury. 38 C.F.R. § 3.310(a). The Court has construed this provision as entailing "any additional impairment of earning capacity resulting from an already service connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service connected condition." Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, the evidence must show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. The provisions of 38 C.F.R. § 3.310 were amended effective October 10, 2006. The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen v. Brown, 7 Vet. App. 439 (1995), it was made clear in the comments to the regulation that the changes were intended to place a burden on the claimant to establish a pre-aggravation baseline level of disability for the non-service-connected disability before an award of service connection based on aggravation may be made. This had not been VA's practice, which strongly suggests that the recent change amounts to a substantive change in the regulation. Given what appear to be substantive changes, and because the veteran's claim was pending before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the change, which is the version that favors the claimant. Back Disability The March 2013 VA examination report and an April 2009 VA x-ray study show that the Veteran has been diagnosed with degenerative changes of the thoracic spine, lumbar spondylosis, and fracture deformities of the lumbar spine, with arthritis confirmed by x-ray findings. Because osteoarthritis is defined as a chronic disease in section 3.309(a), the provisions of subsection 3.303(b) for chronic disabilities apply, and the claim may be established by competent and credible evidence of a continuity of symptomatology after service. Walker, 708 F.3d at 1338-1339. The Veteran's degenerative disc disease of the spine is also eligible for presumptive service connection. Specifically, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, service connection for osteoarthritis may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307; 3.309(a). However, this presumption will be rebutted if there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). The Veteran contends that his back disability was caused or aggravated by his right elbow disability. However, he has not offered any arguments, explanation or evidence in support of this contention. There is no competent evidence of record suggesting that the Veteran's right elbow disability caused or aggravated his back disability. A December 2002 VA treatment record constitutes the earliest dated evidence of a spine disorder, and shows that the Veteran had sustained low back trauma after falling down due to a syncopal episode. An x-ray study showed moderate degenerative lumbar spondylosis and slight reduction along the mid vertebral body level of T11-12 and L1, "suggesting the possibility of compression fractures of undetermined age." In the March 2013 VA examination report, the examiner opined after reviewing the claims file and examining the Veteran that his back disability was not "etiologically related" to his service-connected right elbow disability because the back and the elbow were not anatomically related to each other. The examiner further stated that the etiology of the Veteran's back disorder was most likely secondary to the aging process and not due to any traumas during active service. The Veteran's contention that his back disorder was caused or aggravated by his right elbow disability is outweighed by the March 2013 VA examiner's opinion to the contrary. Whether such a relationship may exist is a medical determination that is too complex to be made based on lay observation alone. Thus, as a layperson, the Veteran does not have the medical expertise to render a competent opinion on this issue. See Jandreau, 492 F. 3d at 1376-77; Barr, 21 Vet. App. at 309. There are no medical opinions or findings of record supporting a relationship between the Veteran's back disorder and his right elbow disability. Thus, none of the Jandreau factors with regard to when lay testimony may be competent are satisfied. See Jandreau, 492 F. 3d at 1376-77. Moreover, the Veteran has not offered any explanation or rationale in support of such a relationship. Thus, the March 2013 VA examiner's opinion against such a relationship, which was rendered by a medical doctor and supported by an explanation, has more probative value and carries more weight than the Veteran's unsupported lay contention. See King, 700 F.3d at 1345; see also Layno, 6 Vet. App. at 469; Madden, 125 F.3d at 1481. Accordingly, the preponderance of the evidence is against a relationship between the Veteran's back disability and his service-connected right elbow disability, either by way of causation or aggravation. Thus, the criteria for entitlement to service connection on a secondary basis have not been satisfied. See 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 448. The preponderance of the evidence also weighs against a direct relationship between the Veteran's back disorder and his period of active service. The service treatment records do not show that a chronic back disability manifested during service. The Veteran reported low back pain in September 1959 which was attributed to a urinary tract infection. There was no mention of any pathology of the back. The February 1960 separation examination report shows that the Veteran's spine was clinically evaluated as normal. The Veteran has not stated that he injured his back or experienced symptoms of back pain during service, and also has not stated that he was treated for or diagnosed with a back disorder at that time. Thus, the preponderance of the evidence shows that a back disorder did not manifest during active service. There is also no evidence of a continuity of symptomatology after service. The Veteran has not stated that he experienced ongoing back problems since active service, and the evidence of record does not otherwise show ongoing back problems since service separation. As noted above, the earliest evidence of back problems is the December 2002 VA treatment record, reflecting that the Veteran sought treatment following trauma to the back in a fall injury. While there was evidence of compression fractures of undetermined age, there is no indication that the Veteran injured his back during active service. The March 2013 VA examiner's opinion also attributed the Veteran's spine pathology to the aging process. Thus, the evidence shows that the Veteran's current back disability is related to post-service, or "intercurrent," causes, thus weighing against a relationship to service. Accordingly there is no evidence showing that a back disorder manifested during service or until many years after separation. Moreover, there is no other evidence supporting an in-service disease, injury, or event relevant to the incurrence or aggravation of a back disorder. The March 2013 VA examiner also found that the evidence did not support a relationship between the Veteran's back disorder and his period of active service. Thus, service connection is not warranted on a direct basis. See 38 C.F.R. § 3.303. Because there is no evidence indicating that osteoarthritis of the spine manifested within one year of service separation, service connection on a presumptive basis is also not warranted. See 38 C.F.R. §§ 3.307, 3.309. In sum, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for a back disorder must be denied. See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. Bilateral Ankle Disorders, Knee Disorders, and Left Shoulder Disorder According to the March 2013 VA examination reports, the Veteran has been diagnosed with bilateral ankle strains, degenerative joint disease of the knees, and left shoulder tendinitis. He contends that his bilateral ankle and knee disorders, and left shoulder disorder, were caused or aggravated by his right elbow disability. However, he has not offered any evidence, arguments or explanation in support of this contention. There is no competent evidence of record suggesting that the Veteran's right elbow disability caused or aggravated his bilateral ankle and knee disorders or left shoulder disorder. In the March 2013 VA examination reports, the examiner opined after reviewing the claims file and examining the Veteran that his bilateral ankle disorders and left shoulder disorder were not secondary to the right elbow disability because the left shoulder and ankles were neither anatomically nor functionally related to the right elbow. Similarly, the examiner found that the Veteran's bilateral knee disorders were not etiologically related to or aggravated by the right elbow disability as these areas were not anatomically related. The examiner further opined that the bilateral ankle and knee disorders were most likely due to the aging process. A March 2009 VA examination report provides similar findings. The examiner stated in that report that the Veteran's bilateral knee and ankle disorders, and left shoulder disorder, were not caused by or the result of the right elbow disorder as the left shoulder, knees, and ankles were in "far different anatomical areas in the body" with different bony structures and nerve supplies. The Veteran's contention that his bilateral ankle and knee disorders, and left shoulder disorder, were caused or aggravated by his right elbow disability are outweighed by the March 2009 and March 2013 VA examiners' opinions to the contrary. Whether such a relationship may exist is a medical determination that is too complex to be made based on lay observation alone. Thus, as a layperson, the Veteran does not have the medical expertise to render a competent opinion on this issue. See Jandreau, 492 F. 3d at 1376-77; Barr, 21 Vet. App. at 309. There are no medical opinions or findings of record supporting a relationship between these claimed orthopedic disorders and his right elbow disability. Thus, none of the Jandreau factors with regard to when lay testimony may be competent are satisfied. See Jandreau, 492 F. 3d at 1376-77. Moreover, the Veteran has not offered any explanation or rationale in support of such a relationship. Thus, the March 2009 and March 2013 VA examiners' opinions against such a relationship, which were rendered by medical doctors and supported by an explanation, have more probative value and carry more weight than the Veteran's unsupported lay contention. See King v. Shinseki, 700 F.3d at 1345; see also Layno, 6 Vet. App. at 469; Madden, 125 F.3d at 1481. Accordingly, the preponderance of the evidence is against a relationship between the Veteran's bilateral ankle, bilateral knee, and left shoulder disorders and his service-connected right elbow disability, either by way of causation or aggravation. Thus, the criteria for entitlement to service connection on a secondary basis have not been satisfied. See 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 448. The preponderance of the evidence also weighs against a direct relationship between the Veteran's bilateral knee, bilateral ankle, and left shoulder disorders and his period of active service. The service treatment records do not show complaints or treatment related to the ankles, knees, or left shoulder. Moreover, the Veteran has not stated that he injured his knees, ankles, or left shoulder during service or that he ever experienced symptoms in these areas during active service. The February 1960 separation examination report shows that the Veteran's feet and bilateral lower and upper extremities were found to be normal on clinical evaluation. Thus, the preponderance of the evidence is against a showing that disorders of the bilateral ankles, knees, and left shoulder did not manifest during active service. There is also no evidence of a continuity of symptomatology after service. The Veteran has not stated that he experienced ongoing symptoms or problems related to the ankles, knees, or left shoulder ever since active service, and there is no evidence of record suggesting otherwise. At the March 2009 VA examination, the Veteran stated that these disorders had their onset several years earlier. The fact that there is no evidence of disorders of the ankles, knees, or left shoulder for decades after service weighs against a relationship between these disorders and active military service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that a proper consideration for the trier of fact is the amount of time that has elapsed since military service, and that evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the Veteran's health and medical treatment during and after military service, as evidence of whether a condition was incurred in service). Further weighing against a relationship to service is the March 2013 VA examiner's findings that the Veteran's bilateral knee and ankle disorders were most likely due to the aging process. Accordingly, service connection is not warranted on a direct basis for the Veteran's bilateral ankle, knee, and left shoulder disorders. See 38 C.F.R. § 3.303. The Veteran's degenerative joint disease of the bilateral knees is also eligible for presumptive service connection. See 38 C.F.R. §§ 3.307, 3.09. However, because there is no evidence indicating that degenerative joint disease of the knees manifested within one year of service separation, service connection on a presumptive basis is not warranted. See id. Accordingly, the preponderance of the evidence is against the Veteran's claims. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for disorders of the bilateral ankles, knees, and left shoulder is denied. See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. V. Increased Rating VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R., Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2012). The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2012). Otherwise, the lower rating will be assigned. Id. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The schedule recognizes that disability from distinct injuries or diseases may overlap. See 38 C.F.R. § 4.14 (2012). However, the evaluation of the same disability or its manifestation under various diagnoses, which is known as pyramiding, is to be avoided. Id. Where entitlement to compensation already has 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). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, which is known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran's right elbow disability has been rated as 10 percent disabling under Diagnostic Code (DC) 5206 (limitation of flexion of the forearm) and DC 5207 (limitation of extension of the forearm). See 38 C.F.R. § 4.71a. The March 2013 VA examination report reflects that the Veteran's right arm is his major or dominant extremity. Thus, where the ratings differentiate between the major and minor extremity, only those pertaining to the major extremity will be discussed. Under DC 5206, limitation of flexion of the forearm to 45 degrees is assigned a 50 percent rating for the major extremity. Limitation of flexion to 55 degrees is assigned a 40 percent rating for the major extremity. Limitation of flexion to 70 degrees is assigned a rating of 30 percent for the major extremity. Limitation of flexion to 90 degrees is assigned a 20 percent rating for both arms. Limitation of flexion to 100 degrees is assigned a 10 percent rating for both arms. Limitation of flexion to 110 degrees is assigned a noncompensable rating for both arms. 38 C.F.R. § 4.71a. Under DC 5207, a 50 percent rating is assigned for extension of the major forearm limited to 110 degrees. A 40 percent rating is assigned for extension of the major forearm limited to 100 degrees. A 30 percent rating is assigned for extension of the major forearm limited to 90 degrees. A 20 percent rating is assigned for extension of the major or minor forearm limited to 75 degrees. A 10 percent is assigned for extension of the major or minor forearm limited to 60 or 45 degrees. Id. With respect to other relevant diagnostic codes pertaining to range of motion of the arm, DC 5213 applies to impairment of supination and pronation. See id. Under DC 5213, loss of pronation beyond the middle of the arc is assigned a 30 percent rating for the major extremity. Loss of pronation beyond the last quarter of the arc, where the hand does not approach full pronation, is assigned a 20 percent evaluation for both extremities. Limitation of supination of 30 percent or less is assigned a 10 percent rating for both arms. Plate I in 38 C.F.R. § 4.71a shows that normal range of motion of the elbow is from 0 degrees of extension to 145 degrees of flexion. Normal pronation of the forearm is to 80 degrees of pronation and 85 degrees of supination. At an October 2006 VA examination, the Veteran reported constant right elbow pain radiating up to the shoulder and down to his forearm. He rated the pain as ranging from a 7 to a 9 on a scale of 1 to 10, with 10 being the most severe. He also described flare-ups in which the pain could be as severe as a 10 with sudden movements or strength activities using his right upper extremity. Shaving, combing his hair, and washing his hair could precipitate these flare-ups, and they were alleviated with massaging his elbow. During flare-ups, he had decreased ability to brush teeth, shave, and wash and comb his hair. He also reported weakness, swelling, and stiffness of the right elbow, as well as cramps and numbness of the entire right arm. However, he did not have locking or abnormal motion. He took prescription medication with partial relief of pain. With regard to occupational impairment, the examiner noted that the Veteran was retired and had worked for the electrical company reading meters for years. He did not retire due to his arm. With regard to activities of daily living, the Veteran stated that he was unable to do chores because of right elbow pain, and also could not do yardwork such as moving the lawn. On physical examination, there was mild bowing of the elbow at 15 degrees deviation towards the radial site. There was no shortening of the right arm compared to the left arm. There was no malunion, nonunion, loose motion, or false joint. There was no ankylosis of the elbow. There was tenderness to palpation at the elbow and brachio-radialis. There was also tenderness at the lateral aspect of the distal humerus. A manual muscle strength test of the elbow's flexion and extension was 4.5/5. On range of motion testing, flexion of the elbow was to 118 degrees, and extension was to 0 degrees. Painful motion began at 118 degrees. The examiner stated that the elbow was limited by pain, weakness, and fatigue, with pain having the major functional impact. The examiner diagnosed status post trauma to the right distal humerus with lateral deformity, mild and old avulsion fracture of the styloid process of the ulna. In the March 2009 VA examination report, the examiner stated that the right elbow disability had severe effects on the Veteran's ability to do chores and bathe, and prevented him from shopping, doing exercise, playing sports, or engaging in recreation. The examiner did not provide range of motion measurements and there are no other clinical findings that differ from the October 2006 VA examination report. An August 2008 bone density report reflects a diagnosis of severe osteopenia on the radius and ulna and mild osteopenia on the distal portions. The March 2013 VA examination report shows flexion of the right elbow to 130 degrees, with pain beginning at 5 degrees. Extension of the elbow was to 0 degrees. After three repetitions of range of motion testing, flexion was to 120 degrees and extension to 0 degrees. The examiner indicated that the Veteran had additional limitation of motion of the elbow following repetitive testing, and that factors contributing to such limitation or functional loss were less movement than normal, excess fatigability, and pain on movement. The Veteran had normal strength of the elbow (5/5) on muscle strength testing with regard to both extension and flexion. He did not have ankylosis of the elbow. The examiner also noted intra-articular fracture with marked varus or valgus deformity. Further, the examiner indicated that supination was limited to 30 degrees or less on the right. However, the examiner did not indicate that pronation was limited to motion lost beyond the last quarter of the arc or motion lost beyond the middle of the arc. The examiner indicated that the Veteran did not have documented arthritis of the elbow based on x-ray studies. The examiner opined that the right elbow disability did not impact the Veteran's ability to work as he had worked for several years without any problems with his right elbow and was now retired. The examiner stated that it was not severe enough to prevent the Veteran from working. The examiner found that the right elbow disability was mild to moderate in severity. The examiner also found that the Veteran still had functional range of motion to perform self care and activities of daily living. The Veteran's loss of supination of the right arm to 30 degrees or less, as reflected in the March 2013 VA examination report, warrants a separate 10 percent rating under DC 5213 throughout the pendency of this claim. See id. Although the March 2013 VA examination constitutes the earliest evidence of limitation of pronation, the earlier examination reports did not address this issue. The Disability Benefits Questionnaire (DBQ) requires VA examiners specifically to address whether there is limitation of pronation. Thus, giving the Veteran the benefit of the doubt, the Board assumes that limitation of pronation of 30 degrees or less has been present throughout the time period on appeal. A rating in excess of 10 percent under DC 5213 is not warranted as there is no indication of further loss of supination beyond the last quarter or middle of the arc, and no evidence that the hand is fixed in supination or pronation. See id. A separate 20 percent rating is also warranted under DC 5209 for residuals of a joint fracture with marked cubitus varus or cubitus valgus deformity, as a clinical finding of this deformity was rendered in the March 2013 VA examination report. See 38 C.F.R. § 4.71a. Although the earlier examination reports did not make this specific clinical finding, they reflect that a deformity of the elbow was observed, and the examiners were not specifically asked to address whether such was characterized as a cubitus varus or valgus deformity, as in the more recent DBQ. Thus, a 20 percent rating is warranted under DC 5209 throughout the pendency of this claim, under the benefit-of-the-doubt rule. See 38 C.F.R. §§ 3.102, 4.3. However, a higher rating of 60 percent under DC 5209 is not warranted as there is no evidence of flail joint of the right elbow. Because there is no evidence during the pendency of this claim showing that the Veteran's right elbow has had flexion limited to 110 degrees or less, or extension limited to 10 degrees or more, even after repetitive testing, ratings in excess of 10 percent under DC's 5206 and 5207 are not warranted. See 38 C.F.R. § 4.71a. Indeed, the ranges of flexion and extension of the right elbow did not even meet the criteria for compensable ratings under these DC's. 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. Further, under 38 C.F.R. § 4.45, consideration must also be given to weakened movement, premature or excess fatigability and incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995) (holding that the criteria discussed in sections 4.40 and 4.45 are not subsumed by the DCs applicable to the affected joint). The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. 38 C.F.R. § 4.59. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). The evidence does not show that the Veteran's right elbow disability is additionally limited by pain, weakness, fatigability, or incoordination beyond the range of motion measurements recorded in the VA examination reports. Even after repetitive testing, the Veteran's range of motion well exceeded the criteria for even a compensable rating for his right elbow disability based on range of motion. Although the March 2013 VA examination report states that pain began at 5 degrees flexion, the Court held in Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) that pain "must actually affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance' [under] 38 C.F.R. § 4.40 in order to constitute functional loss" warranting a higher rating. See id. at 43. Thus, as the objective clinical evidence shows that the Veteran was able to perform repetitive motion of the right elbow well beyond the limitations warranting compensable ratings under DC's 5206 and 5207, a higher rating is not warranted under the DeLuca criteria based on the fact that pain began at 5 degrees. With regard to the Veteran's reported flare-ups, the evidence does not show that the overall level of disability is more severe than the objective findings recorded in the examination reports. Thus, a higher rating is not warranted under the DeLuca criteria. There is no evidence of other symptoms or pathology of the Veteran's right elbow disability to warrant a separate or higher evaluation under any other diagnostic code. The Veteran does not have ankylosis of the elbow (DC 5205), nonunion of the radius and ulna (DC 5210), impairment of the ulna (DC 5211); or impairment of the radius with nonunion in the lower half (DC 5212). See 38 C.F.R. § 4.71a. Moreover, the Veteran has not been diagnosed with arthritis of the right elbow (DC 5003 and DC 5010). See id. Accordingly, higher or separate ratings are not warranted under any other diagnostic code. In sum, separate 20 percent and 10 percent ratings are warranted for a marked cubitus varus or valgus deformity of the right elbow and limitation of supination to 30 degrees or less, in addition to the 10 percent rating already assigned for painful and limited flexion of the elbow. As there is no evidence showing that the Veteran is entitled to a rating in excess of the evaluations already assigned at any point during the pendency of this claim, staged ratings are not appropriate for the relevant time frame. See Hart, 21 Vet. App. at 509-10. The Board has considered whether the Veteran's claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2012); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun, 22 Vet. App. at 114. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). In Thun, 22 Vet. App. at 115, the Court held that the determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. First, as a threshold factor, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. In this regard, the Board must compare 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. See id. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular criteria are found to be inadequate to evaluate the claimant's disability, the Board must determine whether the exceptional disability exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. If so, then under the third step of the inquiry the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the claimant's disability picture requires the assignment of an extraschedular rating. Id. Referral for extraschedular consideration is not warranted. Specifically, with regard to the first Thun factor, a comparison of the Veteran's right elbow disability and the rating criteria does not show "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). His residuals of a right elbow fracture are manifested by symptoms and functional impairment expressly addressed by the rating criteria, including painful and limited motion with regard to flexion and pronation (DC's 5206 and 5213), pain, weakness and fatigability (sections 4.40, 4.45, and 4.59 of the regulations), and a marked cubitus varus or valgus deformity (DC 5209). The Veteran's reported functional limitations, including difficulties with grooming, sports, and recreation, as well as lifting, are expected concomitants of the symptoms and pathology already compensated under the applicable diagnostic codes, which are based on limitations of motion and excursion, as well as pain, weakness, and similar factors, and thus such limitations are within the purview of the schedular criteria. The criteria under all DC's ultimately have in view the functional effects contemplated by such criteria, whether or not such functional limitations are explicitly mentioned. See 38 C.F.R. § 4.1 (providing that the degrees of disability specified in the General Rating Criteria 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). Thus, the Veteran does not have symptoms, pathology, or functional limitations associated with his right elbow disability that have been left uncompensated or unaccounted for by the assignment of a schedular rating. See Thun, 22 Vet. App. at 115. As noted in Thun, the rating criteria are averages and need not account for each individual circumstance in order to be adequate for evaluation purposes. Id. at 115. Rather, the disability must be "exceptional" or "unusual." Consequently, the Board finds that the available schedular evaluations are adequate to rate this disability, and therefore the first Thun factor is not satisfied. In the absence of this threshold finding, there is no need to consider the second step of the inquiry, namely whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). Therefore, referral for extraschedular consideration is not warranted. See id. The issue of whether entitlement to TDIU is warranted based on the Veteran's right elbow disability is deferred, for the reasons discussed in the REMAND portion of this decision below. See 38 C.F.R. §§ 3.340, 4.16 (2012); Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). Accordingly, a separate rating of 20 percent is warranted for a marked cubitus varus or valgus deformity of the right elbow, and a separate 10 percent rating is warranted for limitation of pronation to 30 degrees or less of the right elbow, in addition to the 10 percent rating already assigned for limitation of flexion of the elbow. The preponderance of the evidence is against the assignment of higher or separate ratings based on limitation of motion of the right elbow or other pathology of the elbow. Consequently, the benefit-of-the-doubt rule does not apply, and higher or separate evaluations beyond those already assigned is denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102; 4.3; Gilbert, 1 Vet. App. at 55. ORDER Entitlement to service connection for intervertebral disc herniation of T11 to T12 level and L1 to L3, L5, and S1 (back disability), claimed as secondary to a service-connected right elbow disability, is denied. Entitlement to service connection for a left ankle disorder, claimed as secondary to a service-connected right elbow disability, is denied. Entitlement to service connection for a right ankle disorder, claimed as secondary to a service-connected right elbow disability, is denied. Entitlement to service connection for a left knee disorder, claimed as secondary to a service-connected right elbow disability, is denied. Entitlement to service connection for a right knee disorder, claimed as secondary to a service-connected right elbow disability, is denied. Entitlement to service connection for a left shoulder disorder, claimed as secondary to a service-connected right elbow disability, is denied. Entitlement to a separate rating of 20 percent for a marked cubitus varus or cubitus valgus deformity of the right elbow is granted for the entire period on appeal, subject to the laws and regulations governing payment of monetary benefits. A separate rating of 10 percent, but no higher, for limitation of pronation of the right elbow, is granted for the entire period on appeal, subject to the laws and regulations governing payment of monetary benefits. A rating in excess of 10 percent for limitation of flexion of the right elbow is denied. REMAND In its January 2013 remand, the Board instructed the RO/AMC to send the Veteran a notice letter specific to claims for PTSD based on personal assault, as required under 38 C.F.R. § 3.304(f)(5). Such a letter has not been sent to the Veteran. Under 38 C.F.R. § 3.304(f)(5), if a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Id. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. Id. VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. Id. Accordingly, such a notice letter in accordance with the provisions of 38 C.F.R. § 3.304(f)(5) must be sent to the Veteran. See Stegall, 11 Vet. App. at 271. A new VA medical opinion with regard to the Veteran's PTSD claim is also required. The March 2013 VA PTSD examination report does not sufficiently address the Veteran's alleged in-service stressors or explain why these stressors are not adequate to support a diagnosis of PTSD based on such stressors. Specifically, the Veteran has argued that he was hit over the head with a helmet made of iron by his superior. Indeed, a March 1959 service treatment record shows that the Veteran was treated for a head injury sustained while sleeping in a barracks after someone hit a foot locker and knocked a steel pot (military parlance for a helmet) on to his head. The Veteran also indicated in the February 2013 PTSD questionnaire and at a February 2009 private psychiatric examination that he was mistreated by a sergeant during active service. At the latter, the Veteran also reported having suicidal thoughts during active service but did not carry them out due to religious beliefs. He further reported thoughts of killing his two superiors, and stated that he still remembers the "horrible experiences" he had during active service, and still has flashbacks of them as if they occurred twenty-four hours ago. The psychiatrist diagnosed the Veteran with PTSD and major depression with psychotic features. In the March 2013 VA PTSD examination report, the examiner noted the Veteran's reported history of being abused by another sergeant, but did not complete the section in the Disability Benefits Questionnaire (DBQ) addressing the Veteran's alleged stressors or explain the basis for finding that the Veteran did not have exposure to a traumatic event during service. If there were any question as to whether the examiner thought that the Veteran did experience a potential stressor during active service but that he did not meet the other criteria for a diagnosis of PTSD under the DSM-IV criteria, such as persistent re-experiencing of the stressor, the examiner clarified that the Veteran did "not meet the stressor criteria" (namely "a stressful event due to combat, personal trauma, or other life threatening situations") and "subsequently, he does not meet other DSM-IV criteria for a diagnosis of PTSD." Thus, it is clear that the examiner's conclusion did not derive from a finding that the Veteran did not have a PTSD-related stressor because of a lack of other symptoms associated with a PTSD diagnosis, but the other way around-namely, that because he did not have an in-service stressor, he did not have other symptoms of PTSD. This approach does not adequately explain the basis of the examiner's predicate finding that the stressor criterion was not satisfied, upon which his other findings against PTSD were grounded by a kind of deductive process. Thus, this opinion is not adequate for deciding this claim. See Barr v., 21 Vet. App. at 312. On remand, the examiner should specifically address the Veteran's alleged stressors and provide an opinion as to whether there is evidence of behavior changes during active service or other credible evidence that the Veteran was abused by a sergeant. The examiner should also provide an opinion as to whether the Veteran has PTSD as a result of his alleged in-service stressors, including being hit in the head with a helmet, an incident which is supported by the service treatment records. If the examiner finds that the stressors do not support a diagnosis of PTSD based on such stressors, a complete explanation must be provided. A new VA opinion is also warranted with regard to the Veteran's claim for an acquired psychiatric disorder other than PTSD, as the March 2013 VA examination does not sufficiently address pertinent evidence of record, including the Veteran's lay statements. See Dalton v. Nicholson, 21 Vet. App. 23 (examination found inadequate where examiner did not comment on the Veteran's report of in-service injury and, instead, relied on the absence of evidence in the service treatment records to provide a negative opinion). Specifically, the examiner stated that the Veteran's depressive disorder and cognitive disorder developed many years after service and thus did not meet the "timeline" for service connection. The examiner also stated that there was no indication that the Veteran's depressive disorder was related to his right elbow disorder. The examiner observed that the first VA treatment record showing psychiatric treatment was dated in December 2002, which is decades after the Veteran's separation from active service. However, in the February 2009 private psychiatric examination report and elsewhere, the Veteran reported that he has experienced depression and other psychiatric symptoms ever since he fractured his right elbow during active service. The treating psychiatrist opined in that report that the Veteran's psychiatric symptoms began during service. Moreover, a January 1986 statement by a private treating psychiatrist reflects that the Veteran had been under his care since January 1981, and that he had a diagnosis of anxious and depressive psychoneurosis. Thus, there is probative evidence of record showing a psychiatric diagnosis much earlier than December 2002. On remand, a new VA opinion should be obtained which takes into account this relevant history. Specifically, the examiner should consider the Veteran's statements regarding experiencing psychiatric symptoms since active service, and review the service treatment records. The examiner must also address the findings in the February 2009 private psychiatric examination report. Then, the examiner should render an opinion, based on this review and his or her medical expertise, as to the likelihood that the Veteran's depression and other psychiatric symptoms stem from fracturing his elbow in service or are otherwise related to service, to include the Veteran's reported in-service symptoms. The examiner should also provide an opinion as to whether the Veteran's psychiatric symptoms were caused or aggravated by his service-connected right elbow disorder. In rendering this opinion, the examiner must address a statement by the Veteran dated around 1981 asserting that he was mocked by acquaintances due to his right elbow disorder. Because resolution of the issue of entitlement to TDIU is partly dependent on the outcome of the service connection claims for PTSD or another acquired psychiatric disorder, the Board will defer consideration of this issue at this time. See Harris v. Derwinski, 1 Vet. App 180, 183 (1991) (two issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on the resolution of the second issue). Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Send the Veteran a letter providing the notice set forth in 38 C.F.R. § 3.304(f)(5) for PTSD claims based on in-service personal assault. 2. Provide a VA PTSD and mental health disorders examination, and obtain an opinion as to whether the Veteran has PTSD as a result of one or more alleged in-service stressors. An opinion must also be provided as to whether he has any other acquired psychiatric disorder incurred in or aggravated by active service or caused or aggravated by his service-connected right elbow disability. The following considerations will govern the examination and opinions: a) The entire claims file and a copy of this REMAND must be made available to the medical professional rendering an opinion on this claim. The opining medical professional must note in the opinion that the evidence in the claims file has been reviewed. b) The examiner should specifically address whether or not the confirmed incident of the Veteran's being hit in the head by a helmet while asleep and sustaining a head injury (as shown in a March 1959 service treatment record) supports a diagnosis of PTSD based on this event, with a complete explanation. c) The examiner must also specifically address whether the Veteran's allegation that he was abused by a sergeant during active service is supported by the evidence of record, to include whether there is any evidence of behavior changes during service or other indications that the alleged stressor occurred. The examiner should also provide an opinion as to the likelihood that the Veteran has PTSD as a result of this stressor. d) The examiner must also provide an opinion as to whether the Veteran has any other acquired psychiatric disorder related to active service. In rendering this opinion, the examiner must address the following: i. The Veteran's reported history in the February 2009 private psychiatric examination report, in which he stated that he has experienced depression and other psychiatric symptoms ever since he fractured his right elbow during active service. ii. The February 2009 private psychiatrist's opinion that the Veteran's "emotional derangements arose from" his experiences in Korea during active service, and that he developed his "psychiatric picture" after he fractured his right elbow. iii. A January 1986 statement by a private treating psychiatrist reflecting that the Veteran had been under his care since January 1981, and that he had a diagnosis of anxious and depressive psychoneurosis. iv. The service treatment records, which are negative for treatment or diagnoses of a psychiatric disorder, and reflect that the Veteran was clinically evaluated as psychiatrically normal at separation. e) The examiner must also provide an opinion as to whether the Veteran has an acquired psychiatric disorder caused or aggravated by his service-connected right elbow disorder. In rendering this opinion, the examiner must address the following: i. A statement by the Veteran dated around 1981 asserting that he was mocked by acquaintances due to his right elbow disorder. ii. Whether limitations imposed by the Veteran's right elbow disorder caused OR AGGRAVATED (PERMANENTLY WORSENED) an acquired psychiatric disorder, to include depression. iii. THE EXAMINER MUST USE THE WORD "AGGRAVATION" OR THE PHRASE "PERMANENTLY WORSENED" IN THE OPINION. f) The VA examiner must provide a complete explanation for his or her opinion(s), based on his or her clinical experience, medical expertise, and established medical principles. 3. After the above development is completed, and any other development that may be warranted based on any additional information or evidence received, the RO/AMC should readjudicate the service connection claims for PTSD or another acquired psychiatric disorder, and the issue of entitlement to TDIU, on the merits. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case (SSOC) and afforded a reasonable 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 matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655 (2012). 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). ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs