Citation Nr: 1327104 Decision Date: 08/23/13 Archive Date: 08/29/13 DOCKET NO. 01-02 487A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to an increased rating for residuals of a fracture of the left ankle, with posttraumatic arthritis, currently evaluated as 20 percent disabling. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). 3. Entitlement to service connection for a left knee disability, to include as secondary to the service-connected left ankle disability. REPRESENTATION Appellant represented by: Mark L. Lippman, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Mac, Counsel INTRODUCTION 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 Veteran had active military service from August 1957 to May 1962. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in February 1999 and November 2010 of a Regional Office (RO) of the Department of Veterans Affairs (VA). The Board notes that the February 1999 rating decision denied an increased rating for the left ankle disability. The Veteran filed a claim for TDIU in March 2010, which was denied in the November 2010 rating decision and he perfected his appeal by filing a timely statement in May 2013 appealing the denial, which was accepted in lieu of a Form 9 Appeal. Nevertheless, throughout the appeal period he has claimed that he is unemployable due to his service-connected left ankle disability. A claim for a TDIU is deemed to have been submitted as part of any claim for an increased rating when evidence of unemployability is submitted at the same time as the claim and the Veteran seeks the highest rating possible. See Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Rice v. Shinseki, 22 Vet. App. 447 (2009). In June 2000, the Veteran appeared and offered testimony at a hearing before a Decision Review Officer (DRO). A transcript of that hearing is of record. In January 2001, the Veteran withdrew his request for a Board hearing. In June 2001, the RO re-characterized the service-connected disability as residuals of a fracture of the left ankle with traumatic arthritis, and increased the rating from 10 percent to 20 percent disabling, effective May 31, 2000. In October 2001, the Board granted a rating of 20 percent for residuals of a fracture of the left ankle prior to May 31, 2000, but denied a rating in excess of 20 percent for residuals of a fracture of the left ankle. In a rating decision in November 2001, the RO implemented the Board's decision and increased the rating to 20 percent effective March 17, 1998. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims ("the Court"). Pursuant to a Joint Motion for Partial Remand, in July 2003, the Court vacated the part of the Board's decision that denied an evaluation in excess of 20 percent for residuals of a left ankle fracture with arthritis and an evaluation in excess of 20 percent for residuals of a left ankle fracture prior to May 31, 2000 for further proceedings in compliance with the Veterans Claims Assistance Act of 2000. In light of the Court's order, the issue is as stated on the title page. In August 2003, the Board remanded the case to the RO for further development in compliance with the Court's Order. In July 2005, the Board denied the claim for a rating in excess of 20 percent for residuals of a fracture of the left ankle with traumatic arthritis. The Veteran appealed the Board decision to the Court. In a March 2008 Memorandum Decision, the Court vacated the Board's July 2005 decision and remanded the matter to the Board for readjudication in compliance with Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008); Dingess v. Nicholson, 19 Vet. App. 473 (2006), and 38 U.S.C.A. § 5103(a). The Court noted that the Board found that the Veteran was not entitled to an extraschedular rating because there was "no competent evidence of marked interference with employment due to his left[-] ankle disorder alone." However, the Court stated that the Veteran was not informed how to substantiate his increased rating claim nor was he informed of the evidence that may show the effect that the worsening of his disability has on his employment and daily life, nor was he notified that if an increase in disability was found the rating would be assigned under the applicable Diagnostic Code. The Court also noted that the Veteran should seek adjudication of his TDIU claim if he believes he already has filed that claim. In October 2008, the Board again remanded the claim to the RO for additional development in compliance with the March 2008 Memorandum Decision. In January 2010, the Board remanded the issue of an increased rating for residuals of a fracture of the left ankle to comply with the duty to assist incarcerated veterans with VA examinations. VA records show that the Veteran was scheduled for VA orthopedic examinations in January 2009 and in February 2009 for which he could not report because he was incarcerated. In the October 2008 remand, the Board instructed the RO to afford the Veteran a new VA examination as to the severity of the Veteran's left ankle disability and to determine whether it prevented him from engaging in substantially gainful employment and whether the impairment results in marked interference with employment or frequent periods of hospitalization. Such an examination was scheduled in January 2009, and the Veteran was notified of the time and place of the examination. A handwritten note from a VA medical facility in Manila indicates that a February 2009 examination was not performed because the Veteran "is still in jail." A January 2009 Court order shows that a Philippine Regional Trial Court denied the Veteran's motion to undergo an examination in January 2009. The Court indicated that jurisdiction over the Veteran and the record of the case was with the Court of Appeals. In an April 2009 Resolution from the Manila Court of Appeals, the Court noted that the Urgent Ex-Parte Motion to allow the Veteran to undergo a medical examination on February 19, 2009 was denied, however before further action is to be taken, the Court requested that the Office of Solicitor General (OSG) file a comment on the Veteran's motion to undergo a medical examination. In a Comment dated in May 2009, the OSG noted that there were no supporting documents showing the Veteran's present state of health that would necessitate the need for a medical examination nor was there information regarding the crime the Veteran was convicted of committing. The OSG advised that the Court be guided by previous decisions of the Supreme Court, where the accused was required to prove that the detention would be a health detriment. Subsequently in September 2009 the Manila Court of Appeals denied the Veteran's motion for a medical examination for his heart condition. In a Resolution in October 2010, the Manila Court of Appeals denied the motion for the Veteran to be afforded a VA examination for his heart condition. Based on this evidence, the Board finds that the Philippine courts are not permitting the Veteran to have a VA examination and that the RO has substantially complied with the Board's remand directives in October 2008 and in January 2010. As there has been substantial compliance with the Board's remands, no further action to ensure compliance with the remand directives is required. Stegall v. West, 11 Vet. App. 268 (1998). A review of the Virtual VA paperless claims processing system reveals documents that are either duplicative of the evidence of record or are not pertinent to the present appeal. FINDINGS OF FACT 1. On multiple occasions VA attempted to have the Veteran examined, however the Veteran failed to be examined due to his incarceration. 2. The claims of entitlement to an increased rating for a left ankle disability, TDIU, and service connection for a left knee disability on a direct and secondary basis are not initial original claims. 3. The residuals of the fracture of the left ankle with traumatic arthritis are manifested by plantar flexion limited to five degrees with pain, dorsiflexion limited to five degrees with pain, no inversion or eversion, no ankylosis, and no malunion of the left fibula. 4. The Veteran's service-connected residuals of a fracture of the left ankle, with posttraumatic arthritis do not render him unable to secure or follow a substantially gainful occupation. 5. The left knee disability did not manifest in service, arthritis of the left knee did not manifest within the one year presumptive period or for many years after service, and the left knee disability is not otherwise related to service. 6. The left knee disability is not shown to have been caused or aggravated by the service-connected residuals of a fracture of the left ankle, with posttraumatic arthritis. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for residuals of a left ankle fracture, with posttraumatic arthritis, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5271 (2012). 2. The criteria for the award of TDIU due to service-connected disabilities have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2012). 3. The left knee disability was not incurred in or aggravated by service, nor may arthritis of the left knee be presumed to have been so incurred, and a left knee disability is not proximately due to or the result of a service-connected disease or injury, nor is it aggravated by a service-connected disease or injury. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5013, 5013A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. The VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that the Court in the March 2008 Memorandum decision found that pursuant to Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), the Veteran was not informed how to substantiate his increased rating claim nor of the evidence that may show the effect that the worsening of his disability has on his employment and daily life, nor if an increase in disability was found the rating would be assigned under the applicable Diagnostic Code. Subsequently, the Federal Circuit interpreted 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice, namely evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, and rejected veteran-specific notice as to effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated. The RO provided pre-adjudication and post-adjudication VCAA notice by letters, dated in November 2008, March 2010, and August 2010. The Veteran was notified that the evidence to needed to substantiate the claim for an increased rating must show worsening or increase in severity of the disability and the effect that worsening has on employment, as well as the evidence necessary to substantiate a claim for TDIU and service connection on a direct and secondary basis. He was informed of the evidence that he must submit, what information and evidence would be obtained by VA, and the provisions for disability ratings and for the effective date of the claims. To the extent that the VCAA notice pertaining to the Veteran's claim for an increased rating for a left ankle disability came after the initial adjudication, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The procedural defect was cured as after the RO provided substantial content-complying VCAA notice, the claim was readjudicated as evidenced by the supplemental statement of the case (SSOC), dated in November 2009 and in subsequent SSOCs. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.) Duty to Assist VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the claims. Service treatment records, post-service treatment records, a copy of the DRO hearing transcript, and lay statements have been associated with the record. Additionally, the Veteran was afforded VA examinations in April 1998, July 2000, November 2000, and March 2004. The Court has specifically addressed VA's duty to assist incarcerated Veterans in cases where a VA examination is warranted. VA's duty to assist incarcerated Veterans requires VA to tailor its assistance to meet the peculiar circumstances of confinement, as such individuals are entitled to the same care and consideration given to their fellow Veterans. See 38 U.S.C.A. § 5107(a) (West 2002); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); Bolton v. Brown, 8 Vet. App. 185, 191 (1995). In the case of VA medical examinations, VA does not have the authority to require a correctional institution to release a Veteran so that VA can provide him the necessary examination at the closest VA medical facility. See, e.g., 38 U.S.C.A. § 5711 (West 2002). VA has attempted on multiple occasions, including in January 2009 and February 2009, to provide the Veteran with VA examinations, however, as discussed above, the Philippine courts have denied the Veteran's motions to undergo such an examination. Thus VA has fulfilled its duty to assist the Veteran with the circumstances of his confinement. A VA opinion regarding the Veteran's employability was obtained in July 2010. Under the VCAA, VA is obliged to provide an examination when the record contains (1) competent evidence of a current disability (or persistent or recurrent symptoms of a disability), and (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file to decide the claim. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). However, in the instant case the Board finds that other than the Veteran's naked allegations, the record does not indicate that his left knee disability may be associated with service on a direct basis as there is no evidence of disease or injury in service, recurrent symptoms or continuity of symptomatology since service or other possible association with service nor is there evidence that the left knee disability may be secondary to the service-connected left ankle. For these reasons, a VA medical opinion is not necessary to decide the claim for service connection for a left knee disability, to include as secondary to a service-connected disability. Id. at 81; 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i)(C). In April 2010, written authorization dated in December 2008 was received from the Veteran to obtain treatment record for the left leg, however the Veteran did not provide the full name or address of the facility where he was treated. In a letter in August 2010, the RO asked the Veteran to submit written authorization for each health care provider along with a complete address and specific dates for the condition the Veteran was treated. The Veteran did not reply to this request. Thus, with respect to the Veteran's claims, there is no additional development that needs to be undertaken or evidence that needs to be obtained. Failure to Report for VA Examinations The Veteran was requested to report for VA orthopedic examinations dated in January 2009 and February 2009. As discussed above, the Veteran did not report for the examinations due to his incarceration in the Philippines. The Philippine courts have denied his motions to undergo examinations. See April 2009 Resolution from the Manila Court of Appeals, May 2009 comment from OSG, and October 2010 Resolution of the Manila Court of Appeals. 38 C.F.R. § 3.655(b) clearly specifies that when a claimant fails to report for an examination [without good cause] scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination is scheduled in conjunction with any other original claim, a reopened claim for a benefit that was previously disallowed, or a claim for increase, the claim shall be denied. A claimant failing to report for a scheduled examination must show good cause for not doing so. See 38 C.F.R. § 3.655; see also Engelke v. Gober, 10 Vet. App. 396, 399 (1997); Ashley v. Derwinski, 2 Vet. App. 307, 311 (1992). Review of the record discloses that the Veteran first filed a claim of service connection for a left ankle disability in October 1979. As such, the claim received in March 1998 for an increased rating for the left ankle, which subsumes the TDIU claim, and the claim received in March 2010 for service connection for the left knee on a direct and secondary basis are not original compensation claims. An original claim is defined as the initial formal application on a form prescribed by the Secretary. See 38 C.F.R. § 3.160. In this instance, the Board points out that the Veteran's claims received in March 1998 and in March 2010 fall squarely within the purview of an examination scheduled in conjunction with any other original claim. See 38 C.F.R. § 3.655(b). The Veteran's failure to report for the VA examinations is due to his incarceration. His bad acts are not good cause for his failure to report, and a VA examination was necessary in conjunction with another original claim, and his claims shall be denied by express VA regulation. See 38 C.F.R. § 3.655(b). However, as the Philippine courts are a foreign instrumentality and they have denied the Veteran's motions to undergo a VA examination, the Board alternatively will address the issues on appeal on the merits. Claims Addressed on the Merits The analyses focus on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board provide reasons for rejecting evidence favorable to the Veteran. The pertinent evidence is addressed in detail below. Increased Rating for Residuals of a Fracture of the Left Ankle, with Posttraumatic Arthritis A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings". Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here the disability has not significantly changed during the relevant time period and a staged rating is unwarranted. Rating factors for a disability of the musculoskeletal system include functional loss due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion, weakness, excess fatigability, incoordination, pain on movement, swelling, or atrophy. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). In evaluating musculoskeletal disabilities, the VA must determine whether pain could significantly limit functional ability during flare-ups, or when the joints are used repeatedly over a period of time. See DeLuca 8 Vet. App. at 206. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Court also has recently held, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [, or] endurance." Id., quoting 38 C.F.R. § 4.40. Currently the left ankle is evaluated as 20 percent disabling, therefore the analysis below discusses whether the Veteran meets the criteria for a rating higher than 20 percent for his left ankle. The Veteran's service-connected left ankle disability is rated under Diagnostic Codes 5010-5271. Arthritis due to trauma, substantiated by X-ray findings, is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. 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. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The standard range of motion of the ankle is from 20 degrees of dorsiflexion to 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II. A 20 percent evaluation is warranted for marked limitation of motion, and a 10 percent disability rating requires a moderate limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Other applicable codes include Diagnostic Code 5270 and 5262. Diagnostic Code 5270 (ankylosis of the ankle) provides that a 20 percent rating is warranted for ankylosis in plantar flexion less than 30 degrees. A 30 percent evaluation requires ankylosis in plantar flexion between 30 degrees and 40 degrees or in dorsiflexion between 0 degrees and 10 degrees. A 40 percent rating is warranted for plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. 38 C.F.R. § 4.71a, Diagnostic Code 5270. 38 C.F.R. § 4.71a, Diagnostic Code 5262, a 40 percent disability rating is warranted for nonunion of the tibia and fibula, with loose motion and a brace. For a malunion of the tibia and fibula, 30, 20, and 10 percent disability ratings are warranted for marked, moderate, and slight knee or ankle disabilities, respectively. Facts Service treatment records show that in January 1961 the Veteran fractured his left ankle. Physical examination revealed an abrasion, contusion, and hematoma of the left ankle. X-rays showed a comminuted fracture of the distal fibula with slight widening of the ankle mortise. VA medical records reveal that X-rays of the left ankle taken in June 1980 showed a firmly united fracture of the distal extremity of the shaft of the fibula. The impression was no demonstrated abnormality of the left ankle and a well-united fracture of the distal end of the fibular shaft. In June 1985 X-rays of the left lower leg revealed a healed fracture of the distal fibula in good position. X-rays of the left ankle taken in July 1992 showed an old healed oblique fracture of the distal third of the fibula. The fracture was completely healed and in good alignment. The impression was an old healed fracture of the distal third of the left fibula. In a December 1993 statement, a private doctor reported that the Veteran had the following clinical diagnoses: wound closed, residual fracture, ankle, left, leading to degenerative or traumatic arthritis; arthritis, traumatic, hip, joint, left; osteoarthritis, traumatic, degenerative, lumbar spine; and hypertension, malignant. VA X-rays of the left ankle taken in January 1994 showed a healed oblique fracture of the distal fibula with minimal deformity. The impression was a healed fracture of the distal left fibula. In March 1998, the Veteran requested an increased evaluation for his service-connected left ankle disability. At the time of an April 1998 VA examination, the Veteran reported having pain in his left ankle. Range-of-motion testing in the left ankle revealed that dorsiflexion was to 10 degrees and that plantar flexion was to 30 degrees. The examiner noted that it was painful for the Veteran when he dorsiflexed his left ankle from 10 to 20 degrees. The Veteran had facial grimace with the movement of the left ankle. The examiner noted that the Veteran walked with a slight limp of the left foot. The examiner also indicated that there was no ankylosis. X-rays of the left ankle showed that in comparison to the X-rays taken in January 1994, there was no interval change in the healed oblique fracture of the left distal fibula. The impressions were healed fracture, distal left fibula, unchanged since January 1994, and normal ankle joints. A diagnosis of a healed fracture of the left distal fibula was rendered. In a May 1998 report, a private doctor indicated that the Veteran had persistent severe pain in the left ankle with limitation of movement. The doctor noted that the Veteran could not stand for long on his left foot because of pain. A diagnosis of residuals of a fracture of the left ankle leading to degenerative or traumatic arthritis was rendered. The Veteran was afforded an additional VA examination in July 2000. He reported that he had pain in his left ankle with stiffness and that he could not endure long standing and walking. He stated that he had flare-ups in his left ankle four to five times per month with swelling. He noted that cold weather aggravated his symptoms. He reported that he used a cane during flare-ups. The examiner noted a facial grimace when the veteran dorsiflexed his left ankle. He walked slowly with a limp on the left lower extremity. Dorsiflexion of that ankle was from 0 to 10 with pain and plantar flexion was from 0 to 30 degrees. It was reported that dorsiflexion on flare-ups was from 0 to 5 degrees and that plantar flexion on flare-ups was from 0 to 20 degrees. The examiner indicated that there was no ankylosis. A diagnosis of residuals of a healed left ankle fracture with limitation of motion was rendered. In November 2000, the Veteran reported having moderate to severe pain over his left ankle. He noted that the condition was aggravated by cold weather. He indicated that the pain was constant and that he had no range of motion during flare-ups. The Veteran reported that he walked with a cane due to left ankle pain or weight bearing. Passive and active ranges of motion were the following: dorsiflexion was from 0 to 20 degrees; plantar flexion was from 0 to 10 degrees; and eversion and inversion were to 0 degrees. Pain was present beyond the above noted degrees. Range of motion was limited by pain and bone block due to a malunited lateral malleolus. The examiner noted that a description of ankylosis was not applicable. The Veteran had no push off in his gait due to no plantar flexion of the left foot. X-rays of the left ankle revealed minimal osteoarthritic change in the left ankle joint with joint relationships normally maintained. X-rays of the left tibia and fibula revealed a well-aligned fracture in the distal fibula that was healed and that was without any evidence of old osteomyelitis. A diagnosis of healed fracture of the left distal fibula and posttraumatic arthritis of the left ankle was rendered. The examiner indicated that the Veteran had a healed malunited fracture of the lateral malleolus, left (distal third fibula) resulting in disruption of the mortise of the ankle joint and causing severe limitation of motion to plantar flexion, eversion, and inversion of the left ankle. On VA examination in March 2004, the Veteran claimed that during a flare-up that no motion of the joint was possible. He indicated that he avoided prolonged ambulation and weight bearing and that he was presently unemployed. Physical examination revealed no weakness or lack of endurance. Pain had a major functional impact during a flare-up. There was evidence of painful motion and guarded movement in the left ankle. There was tenderness in the left ankle but no swelling. He had no push off in his gait due to limited plantar flexion. Ankylosis of the left ankle was not present. It was reported that during flare-ups dorsiflexion of the left ankle was to zero degrees and plantar flexion was to zero degrees. Range-of-motion testing in the left ankle revealed that active dorsiflexion was to 5 degrees with pain, and that passive dorsiflexion was to 10 degrees with pain. Active plantar flexion was to 5 degrees with pain, and passive flexion was to 5 degrees with pain. No eversion or inversion was possible with pain on attempt at passive motion. The diagnosis was traumatic arthritis of the left ankle. X-rays of the left ankle in April 2004 revealed an old fracture in the distal third of the left fibula and preserved ankle joint space. Medical records dated in April 2010 from the Department of Justice Correction Bureau in the Philippines show that the Veteran walked with a limp in his left leg, was supported by a cain, and at times complained of pain. In December 2001, and in other statements, the Veteran contended that based on VA examinations in July 2000 and in November 2000 he is entitled to a 30 percent rating for ankylosis in plantar flexion between 30 degrees and 40 degrees or between 0 and 10 degrees under Diagnostic Code 5270. In August 2003, the Veteran stated that the November 2000 examination shows he had a malunited bone fracture and plantar flexion deformity. In September 2003 he contended that he was entitled to a 40 percent rating under Diagnostic Code 5270 for inversion or eversion deformity based on the November 2000 VA examination results. In June 2004, the Veteran claimed that the March 2004 VA examination was consistent with the November 2000 examination and showed deformity in the left ankle. He contended that the VA examiner in November 2000 provided a functional description of ankylosis. In August 2005, the Veteran stated that the March 2004 and November 2000 VA examinations show no pathological everson and inversion was possible. In November 2009, the Veteran reiterated that the VA examinations in November 2000 and March 2004 show ankylosis was anchored with deformity of inversion and eversion. Analysis The veteran is receiving a 20 percent rating for arthritis with limitation of motion of the left ankle under Diagnostic Code 5271 (limitation of motion of the ankle), which is the maximum rating under that code. Therefore, a higher rating under that diagnostic code is not available. Additionally, an increased rating may be based on either actual limitation of motion or the functional equivalent of limitation of motion due to less or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement including during flare-ups and with repeated use. However, the analysis in DeLuca does not assist the veteran, as he is receiving the maximum disability rating for limitation of motion of the ankle. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997) (maintaining that once a particular joint is rated at the maximum level in terms of limitation of motion, there can be no additional disability due to pain). Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." See Dorland's Illustrated Medical Dictionary, 28th edition, p. 86. During the appeal period, dorsiflexion and plantar flexion in the left ankle at most was limited to 5 degrees with pain. During the November 2000 examination eversion and inversion was to 0 degrees, and during the March 2004 VA examination there was no eversion or inversion possible with pain on attempt at passive motion. However, during both examinations the examiner determined that ankylosis was not present. Furthermore, VA examiners on in April 1998 and July 2000 also noted that there was no ankylosis deformity. While the Veteran has a functional decrease in range of motion, the fact remains that the left ankle is not ankylosed. The Veteran alleges that he has ankylosis, including during flare-ups and that he has a deformity in inversion and eversion because he is unable to invert or evert his left ankle. The Board also has considered the Veteran's statements that describe his left ankle pain and discomfort. The Veteran is competent to describe his observations. A veteran is competent to give evidence about what he has experienced or observed. Layno v. Brown, 6 Vet. App. 465 (1994). While the Veteran is competent to report what directions he can move his left ankle, his opinion that he has ankylosis, including with inversion and eversion deformity, is outweighed by the VA opinions in April 1998, July 2000, November 2000, and March 2004, whereby the examiners concluded that the left ankle was not ankylosed. These opinions are highly probative as they reflected the VA examiners' specialized knowledge, training, and experience as to the diagnosis of ankylosis. The Board finds the objective medical findings by skilled professionals are more persuasive which, as discussed above show that the left ankle is not ankylosed. The Veteran's own opinion that he has ankylosis is not consistent with the more probative evidence and is not credible. The Board notes that the Veteran has complained of continuous pain in his ankle throughout the entire appeal period. Ankle pain has also been noted on each VA examination that has been performed. However, loss of functioning arising from pain and any weakness or swelling does not raise the Veteran's level of disability to that akin to ankylosis. The Veteran also asserts that he has a malunion of the fibula. The impression from the VA X-rays taken in June 1980 was that the fracture in the left fibula was well united. VA X-rays of the left ankle taken in June 1985 and July 1992 reflected that the fracture of the left distal fibula was healed and in good alignment. While a minimal deformity was noted on January 1994 VA X-rays of the left ankle, the impression from those X-rays was a healed fracture of the left distal fibula. VA X-rays taken in April 1998 revealed that there was no interval change in the healed oblique facture of the left distal fibula. Although the November 2000 VA examiner diagnosed a malunited fracture of the distal third of the left fibula, VA X-rays taken in November 2000 revealed a well-aligned healed fracture of the left distal fibula. VA X-rays of the left ankle revealed an old fracture in the distal third of the left fibula. The report of those X-rays does not indicate a malunion. The Board places greater weight on the numerous X-rays of the left fibula showing a healed fracture, a good alignment, and no deformity than on the Veteran's statements and the diagnosis of a malunited fracture of the distal third of the left fibula made by the November 2000 VA examiner. In fact, the most recent X-ray interpretation of record, which is dated in 2004, disclosed that the joint relationships were normal. The Board finds that the interpretations by the radiologists of findings on X-ray films are more probative than the statement of the Veteran and the one examiner. The Board finds that there is no malunion of the left fibula. Therefore, a higher rating under Diagnostic Code 5262 is not warranted. As the criteria for a rating higher than 20 percent for the service connected fracture of the left ankle with posttraumatic arthritis have not been demonstrated during the appeal period, the preponderance of the evidence is against the claim, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Extraschedular Consideration While the Board does not have authority to grant an extraschedular rating in the first instance, the Board does have the authority to decide whether the claim should be referred to the VA Director of the Compensation and Pension Service for consideration of an extraschedular rating. 38 C.F.R. § 3.321(b)(1). The governing norm for an extraschedular rating is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or necessitated frequent periods of hospitalization so as to render the regular schedular standards impractical. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology pertaining to his service-connected left ankle. The Board finds that the Veteran's service-connected left ankle is manifested by painful motion, which is contemplated by the rating criteria. For these reasons, the disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is, therefore, adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). TDIU A total disability rating may be assigned where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disability; provided that, in pertinent part, if there is only one such disability, the disability shall be rated at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability rated 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340 , 3.341(a), 4.16(a). Where these percentage requirements are not met, entitlement to a total rating based on individual unemployability on an extraschedular basis may be considered when the claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16(b). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or intercurrent disability. 38 C.F.R. §§ 3.341, 4.19. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. For a veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which places the claimant in a different position than other veterans with the same disability rating. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether a veteran can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Analysis The Veteran is service connected for residuals of a fracture of the left ankle, with post-traumatic arthritis, evaluated as 20 percent disabling. This is his only service-connected disability. Because the appellant does not have a single service-connected disability rated at 60 percent or more, nor does he have multiple service-connected disabilities with a combined disability rating of 70 percent or more, he does not meet the threshold requirements for consideration of a total rating based on individual unemployability due to service-connected disabilities under 38 C.F.R. § 4.16(a). In cases such as this, where these percentage requirements are not met, entitlement on an extraschedular basis may be considered. Essentially, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to a veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. The ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. See Van Hoose v. Brown 4 Vet. App. 361, 363 (1993). The Veteran in multiple statement contends that he cannot work due to his service-connected left ankle. At the June 2000 DRO hearing, the Veteran testified that he had severe pain in his left ankle. He stated that his career was in the food service industry and that he quit working in 1990 because he could no longer stand for long periods of time. In March 2010, the Veteran filed a claim for TDIU and stated he could not work due to arthritis in his left knee and left ankle. He indicated that he had a high school education and last worked as a food and beverage service manager. Under certain circumstances, a lay person is competent to identify a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran's statements that he cannot work are competent and minimally credible as there are medical opinions of record, which are addressed below, whereby the examiners concluded that the Veteran cannot work due to his service-connected left ankle disability. However, for reasons addressed below, the Board finds that the Veteran's lay opinion and the favorable medical opinions are outweighed by the VA opinion dated in July 2010. In a December 1993 statement, a private doctor reported that the Veteran had the following clinical diagnoses: wound closed, residual fracture, ankle, left, leading to degenerative or traumatic arthritis; arthritis, traumatic, hip, joint, left; osteoarthritis, traumatic, degenerative, lumbar spine; and hypertension, malignant. The doctor stated that with the present clinical manifestations and the general physical condition of the Veteran as he aged, there would be a continued increase in severity of the affected areas, resulting in the Veteran being unable to perform any substantial occupation. In a May 1998 report, the same private doctor indicated that the Veteran could not stand for long on his left foot because of pain. The diagnoses were residual fracture of left ankle leading to degenerative or traumatic chronic arthritis, spondylitis L2-3 through L4-5, and osteoporosis of the thoracic spine. The examiner stated that the Veteran's disease will continue to progress as he gets older and he cannot perform any gainful occupation. On VA examination in July 2000, the Veteran indicated that his career was in the food service industry, that he worked in hotels, and that his job requirements included lifting and constantly standing. The examiner stated the Veteran could not endure long standing and walking and rising on heels and toes. In July 2010, a VA opinion was obtained as to whether the Veteran's service-connected residuals of a left ankle fracture prevented him from engaging in gainful employment and whether the impairment resulted in marked interference with employment or frequent periods of hospitalization. The examiner noted that the claims folder was reviewed and opined that the Veteran's total inability to engage in substantial gainful employment is not caused by or a result of his service-connected left ankle fracture nor is marked interference with employment or frequent periods of hospitalization caused by or a result of the service-connected left ankle disability. The examiner explained that the Veteran's fracture in January 1961 adequately healed during service and the Veteran was found to be eligible to continue serving in the military, which was corroborated by an examiner during medical examination in August 1961 who evaluated the lower extremities as normal and found the Veteran to be qualified for an extension of 240 days in the US Navy and to perform all the duties of his rate at sea and in the field. The examiner further noted that the Veteran's separation examination in May 1962 evaluated the Veteran's extremities as normal without any mention of left lower extremity complications of the left ankle fracture. The examiner further found it noteworthy that the Veteran's 2004 left ankle X-rays show an intact ankle joint space with a stable healed fracture site at the distal third fibula with no joint pathology. This X-ray is highly significant as it was taken over four decades after the Veteran fractured his left ankle and was compatible with the Veteran's service treatment, which after his injury document that he was eligible for a 240 day extension in military. The examiner was of the opinion that the fracture of the distal third fibula did not significantly affect the integrity of the left ankle in 1961 and the orthopedic specialists adequately treated the fracture with a cast and preserved the integrity of the left ankle. The examiner asserted that if after more than 40 years the left ankle remains intact and has been preserved in the natural course of the Veteran's daily activities, then there is no reason why the left ankle will not remain intact for the succeeding decade as long as the status quo is maintained and there was no evidence on record of any left ankle derangement due to natural causes. The examiner concluded that the Veteran's total inability to engage in substantial gainful employment is not caused by or a result of his service-connected left ankle disability nor is his claimed marked interference with employment or frequent periods of hospitalization caused by or a result of his service-connected left ankle disability. As presented above, a review of the record shows that there are opinions which are favorable and not favorable to the TDIU claim on appeal. With regard to opinions, the credibility and weight to be attached to an opinion are within the Board's province as finder of fact. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Greater weight may be placed on one opinion over another depending on factors such as reasoning employed and whether the examiner was informed of the relevant facts. Nieves Rodriquez v. Peake, 22 Vet. App. 295 (2008). Among the factors for assessing the probative value of a medical opinion are the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Considering the relative merits of the analytical findings and the details of the opinions, the Board places more weight on the unfavorable VA opinion dated in July 2010 than the Veteran's lay opinion and the favorable medical opinions dated in December 1993 and May 1998. The Board rejects the favorable private medical opinions dated in December 1993 and May 1998 as the same examiner merely speculated that the Veteran's physical condition would increase in severity as he aged thereby precluding him from substantially gainful employment. Furthermore, neither opinion provided a reasoning or rationale for the conclusions reached. A mere conclusion statement is insufficient to allow the Board to make an informed decision as to the weight to assign to the medical statement. Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007). The Veteran's lay evidence is accorded no more probative weight than the private medical doctor's opinions as it merely asserts that he cannot stand for long periods of time and lacks reasoning and provides no rationale as to why he cannot work in a less physically rigorous capacity. Conversely, the July 2010 VA opinion was based on medical principles and applied to the facts of the case. Nieves Rodriquez v. Peake, 22 Vet. App. 295 (2008). The examiner reviewed the evidence of record, considered the nature of the Veteran's left ankle disability, history and relevant longitudinal complaints in proffering his opinion. The examiner acknowledged that the Veteran fractured his left ankle during service, however the examiner was of the opinion that the fracture adequately healed during service as the Veteran qualified for an extension of 240 days in service and his separation examination in May 1962 evaluated his lower extremities as normal. Furthermore, the examiner noted that the Veteran's 2004 left ankle X-rays show a stable healed fracture and opined that if after more than 40 years the left ankle remained intact, there is no reason why it would not continue to remain intact and for these reasons concluded that the Veteran's inability to engage in substantial gainful employment is not caused by or a result of his service-connected left ankle disability. In sum, the Board finds that the most probative evidence establishes that the Veteran is not unable to secure and follow a substantially gainful occupation by reason of his service-connected left ankle disability. Rather, the weight of the evidence shows that the Veteran's service-connected disability does not compromise him to such an extent that he is unable to follow substantially gainful employment. For the reasons stated, the Board has concluded that the Veteran's claim for TDIU due to service-connected disabilities does not warrant referral to the Director of the VA Compensation and Pension Service for extra-schedular consideration. See 38 C.F.R. § 4.16(b). For the foregoing reasons, the preponderance of the evidence is against the claim for TDIU. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b). Service Connection for the Left Knee A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C.A. § 1131. Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for chronic disease such as arthritis, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.310(a). This includes any increase in disability (aggravation) that is proximately due to or the result of a service connected disease or injury. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused or aggravated by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Effective October 10, 2006, the section heading of 38 C.F.R. § 3.310 was retitled "Disabilities that are proximately due to, or aggravated by, service-connected disease or injury." Paragraph (b) of 38 C.F.R. § 3.310 was redesignated as paragraph (c), and a new paragraph (b) was added, which states: (b) Aggravation of nonservice-connected disabilities. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice- connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. Analysis In June 2001, July 2001, and August 2005 the Veteran indicated that arthritis in his left knee is related to his left ankle fracture during service. In a statement in December 1993, the Veteran stated that during service he fractured his left lower leg whereby his neck, lower back, and left hip were pressed by 5 fellow servicemen. He asserted that that he was experiencing severe pain and degenerated mobility in his extremities. Service treatment records show that in January 1961 the Veteran fractured the left ankle during authorized sports. He was playing basketball and twisted his left ankle. Physical examination revealed an abrasion, contusion, and hematoma of the left ankle. X-rays showed a comminuted fracture of the distal fibula with slight widening of the ankle mortise. On separation examination in May 1962, the Veteran's lower extremities were normal. VA X-rays in November 2000 show osteoarthritis of the knees. On VA examination in March 2004, the Veteran claimed that he had left knee pain since 1961. The diagnosis was traumatic arthritis of the left knee. X-rays in April 2004 show mild degenerative joint disease in the knees. X-rays from the Philippine Bureau of Corrections in September 2010 show arthritis of the knee. Here, the service treatment records do not document that the Veteran injured his left knee when he fractured his left ankle. As for the Veteran's statements that he has had left knee pain since service in 1961, the Board finds his statements not to be credible as they are inconsistent with his May 1962 separation examination where he did not complain of left knee pain and his lower extremities were evaluated as normal. The normal in-service findings and the fact that a left knee disability was not identified until many years after service, warrants the conclusion that the left knee disability did not manifest in service or for many years thereafter. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); see also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (the Board may consider in its assessment of a service connection claim the passage of a lengthy period of time wherein the veteran has not complained of the malady at issue). It also follows that left knee arthritis did not manifest within the one year presumptive period after service. See 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Thus, there is no basis for a finding of continuity of symptomatology. As discussed earlier, the evidence is inadequate to warrant an examination or a medical opinion. In general, lay witnesses are competent to testify as to their observations as well as opine on questions of diagnosis and etiology in some circumstances. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay witnesses are competent to testify as to their observations, but this testimony must be weighed against the other evidence of record); Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). See also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau; lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology). The Board has carefully considered the Veteran's lay assertions. The Board acknowledges that a layman is competent to report what he or she experiences through one of the senses. See Layno v. Brown, 6 Vet. App 465, 470 (1994). The Veteran is competent to report symptoms, however his left knee disability, manifested by degenerative changes and diagnosed as degenerative joint disease, may not be experienced through one of the five senses. While the Veteran is competent to report symptoms associated with his left knee disability, such as pain and degenerated mobility, the diagnosis of his left knee disability requires that a person be qualified through education, training, or experience to offer a medical diagnosis. For this reason, his left knee disability diagnosed as degenerative joint disease is not a simple medical condition and the Veteran is not competent to render a diagnosis. Furthermore, the determination as to the etiology of the left knee disability, requires specialized training for a determination as to causation, and is therefore not susceptible of lay opinion. See 38 C.F.R. § 3.159. In this instance, no connection, based on causation has been proposed between the left knee disability and service or the left knee disability and the service-connected left ankle, except for the Veteran's own bare statements that are not competent for reasons stated herein. Under certain circumstances, a lay person is competent to identify a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In the instant case there are no Jandreau exceptions regarding the Veteran's contentions concerning the left knee disability. The Veteran's left knee disability manifested by degenerative joint disease is not a simple medical condition he is competent to identify, he is not reporting a contemporaneous diagnosis and has not described symptoms that supported a later diagnosis by a medical professional. The Board finds that there is no probative evidence in the record suggesting that the left knee disability is related to service or is caused or aggravated by the service-connected left ankle disability. As the Veteran's statements regarding the etiology of the left knee disability are not competent the issue of credibility on this particular matter is not reached. Arthritis is included among the chronic diseases under 38 U.S.C.A. 1101 and 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, no left knee pathology was "noted" during service. More specifically, arthritis of the knee was not diagnosed or identified during service. In addition characteristic manifestations of the disease process were not noted during service or within the first year of separation. Therefore, inasmuch as the evidence weighs against a relationship to service or to the service-connected left ankle disability, the record affords no basis to grant service connection for the left knee disability on a direct basis or as secondary to the service-connected left ankle disability. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, the preponderance of the evidence is against the claim, and the claim must be denied. See 38 U.S.C.A. § 5107(b); see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER Entitlement to a rating higher than 20 percent for residuals of a fracture of the left ankle, with posttraumatic arthritis, is denied. Entitlement to TDIU due to service-connected disabilities is denied. Entitlement to service connection for a left knee disability, to include as secondary to the service-connected left ankle disability, is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs