Citation Nr: 1323507 Decision Date: 07/24/13 Archive Date: 08/01/13 DOCKET NO. 09-07 423 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a right ankle disability, to include as secondary to a service-connected right foot disability. 2. Entitlement to service connection for a left ankle disability, to include as secondary to a service-connected right foot disability. 3. Entitlement to an evaluation in excess of 10 percent for service-connected chronic right patellofemoral syndrome with mild patellar tendonitis. 4. Entitlement to an evaluation in excess of 10 percent for service-connected chronic mild lumbar muscular spasms. REPRESENTATION Veteran represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty from May 2000 to April 2002. This matter comes to the Board of Veterans' Appeals (Board) on appeal from January 2008 and April 2010 decisions by which the RO, in pertinent part, denied entitlement to the benefits sought herein. In July 2009, the Veteran testified at a hearing before a Decision Review Officer (DRO) at the RO. In May 2013, the Veteran testified at a hearing before the undersigned Acting Veterans Law Judge via video teleconference. The Veteran's representative was not present at the hearing. Upon questioning by the undersigned, the Veteran indicated that she wished to present testimony at the hearing despite the absence of her representative. The issue of entitlement to an evaluation in excess of 10 percent for service-connected chronic mild lumbar muscular spasms is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The service-connected right knee disability is manifested by no more than a moderate disability picture to include limitation of motion with pain, swelling, locking, and popping. 2. A right ankle disability was not incurred in active duty service, is not otherwise shown to be causally related to service, and it is not the proximate result of a service-connected disability. 3. A left ankle disability was not incurred in active duty service, is not otherwise shown to be causally related to service, and it is not the proximate result of a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a 20 percent disability rating, but no higher, for the service-connected right knee disability are met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5257 (2012). 2. A right ankle disability was not incurred in or a result of active duty service, and a right ankle disability is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 3. A left ankle disability was not incurred in or a result of active duty service, and a right ankle disability is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VCAA and implementing regulations impose obligations on VA to provide those claiming VA benefits 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 timely August 2007, July 2009, and November 2009 letters, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate claims as well as what information and evidence must be submitted by the Veteran and what evidence VA would obtain. The notice included provisions for disability ratings and for the effective date of the claim. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. The record contains the service treatment records, VA clinical records, private treatment records, the Veteran's statements to include hearing testimony, and relevant VA examination reports. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the March 2010 and November 2011 VA medical opinions obtained in this case are adequate. The opinions provided considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided complete rationales for the opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues decided herein has been met. 38 C.F.R. § 3.159(c)(4). For the foregoing reasons, the Board finds that VA has fulfilled its duties to notify and assist the Veteran. Standard of Review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3 (reasonable doubt to be resolved in veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Increased Ratings Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). The Veteran's service-connected right knee patellofemoral syndrome with mild patellar tendonitis has been rated 10 percent disabling by the RO under the provisions of Diagnostic Code 5261. 38 C.F.R. § 4.71a. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes 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 codes, a rating 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 Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Provisions related to the knees specifically are set forth in Diagnostic Codes 5256 through 5263. 38 C.F.R. § 4.71a (2012). Specifically, Diagnostic Code 5256 governs ankylosis of the knee. Id. Diagnostic Code 5258 pertains to dislocation of the semilunar cartilage. Id. Diagnostic Code 5259 regards the symptomatic removal of the semilunar cartilage. Id. Diagnostic Code 5262 deals with impairment of the tibia and fibula. Id. Diagnostic Code 5263 is relevant to genu recurvatum. Id. Diagnostic Codes 5260 and 5261 set forth rating criteria for limitation of motion of the leg. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2012). The normal range of motion in the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2012). With respect to limitation of leg flexion, Diagnostic Code 5260 provides a zero percent rating for flexion limited to 60 degrees, 10 percent for flexion limited to 45 degrees, 20 percent for flexion limited to 30 degrees, and a maximum of 30 percent for flexion limited to 15 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5261, which governs limitation of leg extension, provides a zero percent rating for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for extension limited to 15 degrees, 30 percent for extension limited to 20 degrees, 40 percent for extension limited to 30 degrees, and a maximum of 50 percent for extension limited to 45 degrees. 38 C.F.R. § 4.71a. VAOPGCPREC 9-2004 interprets that a claimant who had both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Code 5003 and instability of a knee under Diagnostic Code 5257. See VAOPGCPREC 23-97. When X-ray findings of arthritis are present and a veteran's knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Diagnostic Code 5257 governs other impairment of the knee. It assigns respective ratings of 10, 20, and 30 percent for slight, moderate, or severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a. An April 2007 magnetic resonance imaging (MRI) of the right knee indicated intact collateral and cruciate ligaments and no meniscal tear as well as infrapatellar and suprapatellar plica with mild fat pad edema in the suprapatellar pouch. During a May 2007 private orthopedic consultation, the Veteran complained of right knee pain with some tenderness and swelling. The Veteran could not run or engage in other athletic pursuits due to right knee swelling. On objective examination, there was good right knee range of motion with some tightness over the lateral retinacular structures. There was tenderness but no instability of the right knee, and strength was good. An X-ray study was negative. The physician diagnosed right knee patellofemoral syndrome and right knee iliotibial tendinitis that was "quite severe." On VA examination in September 2007, the Veteran reported constant right knee pain that was a five to seven in intensity on a scale of one to 10. She reported locking as well as giving way. Objectively, there was a positive patellar grind test. There was no additional functional impairment due to pain, pain on repetitive use, fatigue, weakness, lack of endurance, or incoordination. The diagnosis was of chronic right patellofemoral syndrome. On VA examination in December 2008, the Veteran reported right knee pain as well as popping and indicated that she could not run or jump without exacerbating right knee pain. Objectively, there was no right knee swelling or edema, but there was crepitus. Right knee range of motion was from zero to 140 degrees. The examiner diagnosed mild chondromalacia of the right knee. A March 2009 VA progress note indicated the presence of right knee pain. A March 2009 right knee MRI revealed that the right knee, to include the lateral meniscus, was normal. At the July 2009 DRO hearing, the Veteran testified that she had right knee swelling after walking. The swelling occurred on a daily basis. With locking, she indicated that she wiggled her knee until it settled. She indicated that she had fallen a few times because her knee gave way. An October 2011 private medical report indicated that there was bilateral knee osteoarthritis. The report did not indicate that the assessment was based on a radiologic study. The Veteran was afforded a VA orthopedic examination in November 2011. The diagnoses were of right knee patellofemoral syndrome, right flexion contracture of the knee, and right pes anserine bursitis. The Veteran described right knee pain that had worsened over time. She complained of frequent popping, catching, and grinding underneath her knee cap. There was also swelling with activity such as walking and climbing stairs. The Veteran denied instability and stated that she had never experienced patellar dislocation. She did experience some catching of the knee that required her to wiggle the knee to get it to "uncatch." Flare-ups occurred daily due to quotidian activities such as walking up and down stairs. Right knee pain was a nine on a scale of one to 10 during flare-ups. The Veteran stated that flare-ups could last for days and interfered with her ability to perform some daily activities. Right knee range of motion was from 5 degrees of extension to 120 degrees of flexion with pain starting at 90 degrees. The Veteran was able to perform repetitive use testing, and right knee range of motion was unchanged after several range of motion exercises. Functional impairment included loss of motion, pain on motion, and interference with sitting, standing, and weight-bearing. Additionally, there was tenderness to palpation of the right knee. The Veteran had a right knee meniscus condition manifested by frequent episodes of joint pain and effusion. The Veteran had never undergone a meniscectomy. There was right knee crepitus, and the Veteran walked with an antalgic gait. She used a knee brace on occasion. X-ray studies did not show degenerative or traumatic arthritis or patellar subluxation. The cartilage was normal without any meniscal tear. The Veteran indicated that she felt that her right knee disability hindered her ability to work due to pain with ambulation and prolonged standing. The examiner noted that there was no evidence of patellar laxity or instability. There was no evidence of arthritis. Medial pain was likely due to pes arsenine bursitis, which was unrelated to the service-connected disability. The flexion contracture was also unrelated to the service-connected disability. However, the symptoms associated with the service-connected and nonservice-connected right knee disabilities could not be distinguished. At the May 2013 Board hearing, the Veteran testified that she experienced locking, snapping, popping, and cracking of the right knee. According to the Veteran, the right knee locked. Walking up and down stairs was difficult. The Veteran stated that she did not recall falling following an episode of right knee locking. The Board notes that it will consider all symptoms attributed to the right knee because the symptoms associated with the service-connected right knee disability and the nonservice-connected right knee disabilities cannot be distinguished. See Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (holding that the Board is precluded from differentiating between the symptomology attributable to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so). The Board also observes that certain scheduler provisions related to the knee are not applicable herein. Diagnostic Code 5256, which governs ankylosis of the knee, does not apply because no ankylosis of the right knee is present. Diagnostic Code 5258 pertains to dislocation of the semilunar cartilage; it is inapplicable because dislocation of the semilunar cartilage is not shown. Diagnostic Code 5259, which regards the symptomatic removal of the semilunar cartilage, need not be considered because the semilunar cartilage has not been removed. Diagnostic Code 5262 deals with impairment of the tibia and fibula; it is not relevant herein because the tibia and fibula are not implicated. Finally, Diagnostic Code 5263, which pertains to genu recurvatum is inapplicable because this manifestation is not present in the Veteran. The Veteran's right knee range of motion is from five to 120 degrees. Because flexion is to 120 degrees, a compensable evaluation is not warranted under Diagnostic Code 5260. The Board notes that pain starts at 90 degrees of flexion. However, even if the Board were to use this measurement, a compensable evaluation would not be warranted under Diagnostic Code 5260. Under Diagnostic Code 5261, an evaluation in excess of 10 percent is not warranted because such a rating would require that extension be limited to 15 degrees, and the Veteran does not suffer from such limitation of right knee extension. The Board now turns to Diagnostic Code 5257. While the evidence is ambiguous regarding giving way and falling, the recurrent locking along with other symptoms such as popping, swelling, and pain are symptoms that are tantamount to a moderate recurrent subluxatrion. Thus, a 20 percent evaluation is warranted under Diagnostic Code 5257. A 30 percent evaluation is not warranted under Diagnostic Code 5257 because severe recurrent subluxation has not been shown. The objective evidence has not pointed to severe recurrent subluxation or lateral instability, and the Veteran has not described symptoms consistent with severe symptomatology in this regard. The Veteran's right knee disability picture has been fairly consistent throughout the appeal period, and the 20 percent evaluation under Diagnostic Code 5257, therefore, applies throughout. Hart, supra. The Board emphasizes that it is permissible to change the diagnostic code under which a veteran is rated. The assignment of a particular diagnostic code is completely dependent on the facts of a particular case. Butts v. Brown, 5 Vet. App. 532 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Tedeschi v. Brown, 7 Vet. App. 411 (1995). As explained above, a rating under Diagnostic Code 5257 better characterizes the Veteran's right knee disability picture. Thus, it is more appropriate than a rating under Diagnostic Code 5261. The Board finds that the Veteran does not suffer from right knee arthritis because a multitude of radiologic studies, to include MRIs, have indicated that arthritis is not present. Jefferson v. Principi, 271 F.3d 1072, 1076 (Fed. Cir. 2001) (recognizing the Board's inherent fact-finding ability). Indeed, although arthritis was mentioned in October 2011, a subsequent VA examination report indicated that there was no right knee arthritis. Thus, a separate rating under Diagnostic Code 5003 need not be considered. See VAOPGCPREC 23-97 and VAOPGCPREC 9-98. In the present case, it should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 (2012) 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 (2012) provides that consideration also be given to weakened movement, excess fatigability and incoordination. The Board has taken all of the Veteran's symptoms into account when assigning the 20 percent disability rating herein. Thus, to the extent that the types of symptoms described above are present, they have been considered. Additional compensation for the same symptomatology would result in prohibited pyramiding. 38 C.F.R. § 4.14. The Court held that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total disability rating based on individual unemployability (TDIU) as a result of that disability is warranted. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has been awarded a TDIU rating effective October 17, 2009. The Board finds that a claim for a TDIU is not raised by the record before that date. Specifically, the evidence of record fails to show that the Veteran was unemployable before October 17, 2009. Therefore, the Board finds that no further consideration of a TDIU is warranted. Id. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant an even more favorable decision. Extraschedular Consideration The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2012), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath, 1 Vet. App. at 593. The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "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). If the evidence raises the question of entitlement to an extraschedular rating, 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. 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. Thun v. Peake, 22 Vet. App. 111 (2008). In Mittleider, the Court held that the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition. Mittleider, 11 Vet. App. at 182. Here, the Board has considered Mittleider and has attributed all potentially service-connected symptoms to one service-connected condition or another, before considering if the Veteran is entitled to an extraschedular rating The Board finds that the schedular rating criteria contemplate the symptoms and impairment caused by the Veteran's service-connected right knee disability. The criteria specifically provide for ratings based on limitation of motion, including due to pain and other limiting orthopedic factors, as well as ratings based on recurrent subluxation and lateral instability. The service-connected right knee disability rating criteria specifically provide for ratings based on the presence of painful arthritis and limitation of motion, if such are present, although the Board found in this instance that arthritis of the right knee was not present. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); see also DeLuca. Because the schedular rating criteria are adequate to rate the Veteran's service-connected right knee disability, 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 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. § 1110; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). The Board notes that 38 C.F.R. § 3.303(b) applies only to the chronic diseases, such as arthritis, enumerated in 38 C.F.R. § 3.309(a). See generally Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board observes that a chronic disease is not shown with respect to the Veteran's ankles and 38 C.F.R. § 3.303(b) does not apply. 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). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. 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. 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. 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). Factual Background The service treatment records reflect that the Veteran underwent right foot surgery in service and that the right foot and ankle were immobilized for an extended period. A notation in the service treatment records revealed right ankle pain. Otherwise, the service treatment records reflect no injuries or abnormalities related to the ankles. A May 2009 MRI of the right ankle indicated changes consistent with a mild sprain, mild tenosynovitis, subtalar effusion, cystic structures, and no osseous abnormalities. On VA examination in March 2010, the Veteran asserted that the in-service right foot surgery caused the right foot to function differently, which went on to cause bilateral ankle instability. According to the Veteran, both ankles were similar. She denied a history of recurrent ankle sprains. She merely indicated that her ankles were unstable and weak. A right ankle X-ray study revealed a Mitek suture anchor in the lateral malleolus with no acute fractures, no malalignment, and no significant degenerative changes. An X-ray study of the left ankle revealed no acute fractures, no malalignment, and no degenerative changes. An os trigonum was present. The examiner diagnosed right ankle instability and left ankle instability. The examiner opined that the Veteran's bilateral ankle instability was not likely due to any gait change caused by the Veteran's in-service right foot surgery. The examiner based the opinion on the bilaterality of the condition, particularly because there was no history of recurrent ankle sprains. Because the laxity was similar in both ankles, it was more likely that such laxity was due to the natural tensioning of the Veteran's ankle ligaments and tendons. In September 2011, the Veteran underwent ankle surgery. The post-operative diagnosis was of left symptomatic ankle instability and of a right prominent ankle suture. At the March 2013 Board hearing, the Veteran testified that following right foot surgery in service, she could not stand on the right foot for a year, which weakened her right ankle. As to the left ankle, she stated that it was weakened due to the overuse that occurred when she could not use the right lower extremity. She also indicated that an altered gait caused the ankle disabilities. Discussion As stated, the Veteran contends that she has bilateral ankle disabilities that are related to a service-connected right foot disability. Specifically, she maintains that her right ankle was weakened from lack of use following an in-service right foot surgery and that the left ankle disability is due to overuse engendered by the immobilization of the right lower extremity following the surgery. She also contends that an altered gait due to the service-connected right foot disability caused the bilateral ankle disabilities. The Veteran is competent to report symptoms readily apparent through the senses. See, e.g., Layno, supra. The Board does not dispute the fact that she suffers from bilateral ankle instability and weakness. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, which involves the inner workings of the ankles, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Thus, because the Veteran is a lay person, the Board cannot credit her theories as to the etiology of her claimed bilateral ankle disabilities. There is only one competent medical opinion of record regarding the etiology of the Veteran's right and left ankle conditions, namely that of the March 2010 VA examiner. The VA examiner explained that because the Veteran's ankles were similar bilaterally any weakness was due to the specific nature of the tension of the structures in her ankles and not to any changes or abnormalities caused by the service-connected right foot disability. It follows from this fully reasoned opinion that service connection for the claimed bilateral ankle disabilities is not warranted as secondary to the service-connected right foot disability. 38 C.F.R. § 3.310. Implicit in the March 2010 examiner's opinion is that there is no direct relationship between a right or a left ankle disability and service, as the ankle conditions are inherent to the Veteran and not caused by an outside factor. As such, service connection for a right and/or left ankle disability on a direct basis is denied. 38 C.F.R. § 3.303. This is not a case where the evidence for and against the claims is in relative equipoise. Rather, the entirety of the competent and probative evidence is against the right and left ankle claims. In such situations, the benefit of the doubt rule does not apply. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Alemany, supra. ORDER An evaluation of 20 percent for the service-connected right knee disability is granted subject to the law and regulations governing the payment of veterans' benefits. Service connection for a right ankle disability is denied. Service connection for a left ankle disability is denied. REMAND A remand is required in this case to assist the Veteran with her claim of entitlement to an evaluation in excess of 10 percent for service-connected chronic mild lumbar muscular spasms. The Veteran was last afforded a VA examination concerning the low back in March 2010. In May 2013, she testified regarding her service-connected low back disability at a hearing before the undersigned. The symptoms she described at the hearing are far more severe than those enumerated in the March 2010 VA examination report. Due to the reports of worsening symptomatology and given the fact that some three and a half years have elapsed since the low back was last comprehensively evaluated, a new VA spine examination is warranted. To ensure that the record is complete, all VA clinical records dated from November 30, 2011 to the present should be associated with the claims file. Accordingly, this matter is REMANDED to the RO/AMC for the following action: 1. Associate with the claims file all VA clinical records dated from November 30, 2011 to the present. 2. Schedule a VA orthopedic examination to determine the current severity of the Veteran's service-connected low back disability. The examiner must describe all symptoms and manifestations of the veteran's low back disability including accurate range of motion measurements. The examiner should comment on whether the following manifestations are present and, if so, whether they are related to the service-connected low back disability: muscle spasm, guarding severe enough to result in an abnormality gait or abnormality spinal contour such as scoliosis, reversed lordosis, or abnormality kyphosis. The examiner should identify any objective evidence of pain or functional loss due to pain associated with the service-connected disability. The examiner should be requested to provide an opinion as to the extent that low back pain limits the Veteran's functional ability. The examiner should also be requested to determine whether, and to what extent, the low back exhibits weakened movement, excess fatigability, or incoordination. A rationale for all conclusions must be provided. All pertinent documents in the claims folder, including all existing service medical records, must be made available to the examiner for review in conjunction with the examination. In the report, the examiner must indicate whether the claims file was reviewed and identify the records on which he or she relied. 3. Readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran and her representative should be provided a Supplemental Statement of the Case, which reflects consideration of all additional evidence, and the opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matter 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 or by the Court 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). ______________________________________________ MATTHEW D. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs