Citation Nr: 1330641 Decision Date: 09/24/13 Archive Date: 09/30/13 DOCKET NO. 07-01 066 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a rating in excess of 30 percent for adjustment disorder with anxiety and depression symptoms prior to February 4, 2013, an in excess of 50 percent thereafter. 2. Entitlement to an initial compensable rating for hypertension. 3. Entitlement to service connection for a low back disability, to include as secondary to service-connected residuals of right and left ankle sprains. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Arif Syed, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1978 to November 1992. This case is before the Board of Veterans' Appeals (Board) on appeal from January 2005, July 2006 and April 2008 rating decisions rendered by the Houston, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). In February 2011, the Veteran testified at a travel Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of this hearing is associated with the claims folder. Additionally, evidence has been associated with the Veteran's claims folder included with a waiver of RO consideration. In November 2012, the Board remanded the Veteran's claims. In an April 2013 rating decision, the Appeals Management Center (AMC) awarded the Veteran a 50 percent disability rating for his adjustment disorder effective February 4, 2013. However, as the increase did not constitute a full grant of the benefits sought, the Veteran's claim for a higher evaluation remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). Additionally, the AMC continued the previous denial of the hypertension and low back disability claims in an April 2013 supplemental statement of the case (SSOC). Accordingly, the Veteran's VA claims folder has been returned to the Board for further appellate proceedings. The Board has reviewed the Veteran's claims folder and the record maintained in the Virtual VA paperless claims processing system. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) as a result of service-connected coronary artery disease has been raised by the record (see February 2011 hearing transcript and January 2011 statement from Dr. E.W.), but has not been adjudicated by the agency of original jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Prior to February 4, 2013, the Veteran's adjustment disorder with anxiety and depression symptoms was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as sleep disturbance, impaired judgment, depression, difficulty adapting to stressful circumstances, disturbances of motivation and mood, anxiety, obsessive behavior, and difficulty in establishing effective work and social relationships. 2. From February 4, 2013, the Veteran's adjustment disorder with anxiety and depression symptoms is manifested by occupational and social impairment with deficiencies in most areas due to such symptoms as sleep disturbance, difficulty adapting to stressful circumstances, difficulty concentrating, depression, anxiety, persistent avoidance, obsessive behavior, increased arousal, impaired impulse control, social isolation, and inability to establish and maintain effective relationships. 3. Hypertension has been manifested by diastolic pressure readings predominantly below 100, and by systolic pressure readings below 160. 4. The Veteran's current low back disability is not related to any disease or injury shown in service and any low back disability that preexisted active service was clearly and unmistakably not aggravated therein; nor is the low back disability caused or aggravated by service-connected right and left ankle disabilities. CONCLUSIONS OF LAW 1. Prior to February 4, 2013, the criteria for an evaluation of 50 percent, but no higher, for adjustment disorder with anxiety and depression symptoms have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9422 (2012). 2. From February 4, 2013, the criteria for an evaluation of 70 percent, but no higher, for adjustment disorder with anxiety and depression symptoms have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9422 (2012). 3. The criteria for an initial compensable evaluation for hypertension have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). 4. A low back disability was not incurred in or aggravated by active military service and is not caused or aggravated by service-connected right and left ankle disabilities. 38 U.S.C.A. §§ 1110, 1111, 1131, 1153 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks entitlement to increased disability ratings for his service-connected adjustment disorder and hypertension as well as entitlement to service connection for a low back disability, to include as secondary to service-connected right and left ankle sprains. In the interest of clarity, the Board will discuss certain preliminary matters. The issues on appeal will then be analyzed and a decision rendered. Stegall concerns As alluded to above, in November 2012, the Board remanded these claims and ordered the agency of original jurisdiction (AOJ) to provide the Veteran with VA examinations and associate reports of the examinations with his claims folder. The Veteran's claims were then to be readjudicated. Pursuant to the Board's remand instructions, the Veteran was provided VA examinations as to his adjustment disorder, hypertension, and low back disability in February 2013 and reports of the examinations were associated with his claims folder. The Veteran's claims were readjudicated via the April 2013 SSOC. Accordingly, the Board's remand instructions have been complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. The Veterans Claims Assistance Act of 2000 The Board has given consideration to the Veterans Claims Assistance Act of 2000 (VCAA). The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also defines the obligations of VA with respect to its statutory duty to assist a claimant in the development of his claim. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). Notice The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In the case at hand, the record reflects that the originating agency provided the Veteran with the required notice by letters mailed in June 2004, December 2005, and October 2007, and notice with respect to the effective-date element of the claim, by the October 2007 letter. Although the October 2007 letter including the effective-date element of the claim was provided after the initial adjudication of the hypertension and low back disability claims, the Board finds that the Veteran has not been prejudiced by the timing of this letter. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the completion of all indicated development of the record, the AMC readjudicated the Veteran's claims in the April 2013 supplemental statement of the case. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). There is no indication or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law affords that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In the instant case, the Board finds reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims. There is no reasonable possibility that further assistance would aid in substantiating the claims. The pertinent evidence of record includes the Veteran's statements, service treatment records, as well as VA and private treatment records. The Veteran was afforded VA examinations in November 2007, August 2009 and February 2013 for his adjustment disorder; in October 2004, June 2007, and February 2013 for his hypertension; and in April 2006 and February 2013 for his low back disability. The examination reports reflect that the examiners interviewed and examined the Veteran, reviewed his claims folder, reviewed his past medical history, documented his current medical conditions, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. Furthermore, these examination reports contain sufficient information to rate the Veteran's adjustment disorder and hypertension under the appropriate diagnostic criteria. The Board therefore concludes that the VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. As noted above, the Veteran also was afforded a hearing before the undersigned VLJ during which he presented oral argument in support of his increased rating and service connection claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issues on appeal during the hearing and specifically discussed the Veteran's adjustment disorder, hypertension, and low back symptomatology, and suggested the submission of evidence that would be beneficial to the Veteran's claim, namely evidence pertaining to the Veteran's adjustment disorder and hypertension symptomatology as well as evidence indicating a nexus between the Veteran's low back disability and his military service or right and left ankle disabilities. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the criteria necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the criteria necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the law and that no further action pursuant to the VCAA need be undertaken on the Veteran's behalf. Accordingly, the Board will proceed to a decision. Increased Ratings Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4 (2012). 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. See 38 C.F.R. § 4.7 (2012). A request for an increased rating must be viewed in light of the entire relevant medical history. See 38 C.F.R. § 4.1 (2012); see also Peyton v. Derwinski, 1 Vet. App. 282, 287 (1991). However, where entitlement to compensation has already been established and increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that "staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 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 issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (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. Psychiatric Disability The Veteran's psychiatric disorder is currently rated under 38 C.F.R. § 4.130, Diagnostic Codes 9499-9422 (2012). See 38 C.F.R. § 4.27 (2012) [hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen]. Diagnostic Code 9422 is deemed by the Board to be the most appropriate because it pertains specifically to the primary diagnosed disability in the Veteran's case-adjustment disorder with anxiety and depression symptoms. In any event, with the exception of eating disorders, all mental disorders are rated under the same criteria in the rating schedule. Therefore, rating under another diagnostic code would not produce a different result. Moreover, the Veteran has not requested that another diagnostic code be used. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 9422. The Veteran's adjustment disorder with anxiety and depression symptoms is to be rated under the general rating formula for mental disorders under 38 C.F.R. § 4.130. The pertinent provisions of 38 C.F.R. § 4.130 concerning the rating of psychiatric disabilities read in pertinent part as follows: 100 percent: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation or name. 70 percent: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. 50 percent: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty establishing effective work and social relationships. 30 percent: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). See 38 C.F.R. § 4.130, Diagnostic Code 9422 (2012). It is noted that the "such symptoms as" language of the diagnostic code listed above means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples need not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130 (2012) [incorporating by reference the VA's adoption of the DSM-IV for rating purposes]. The Veteran was afforded a VA examination for his psychiatric disorder in November 2007. The Veteran reported that he had been married three times and had six children. He further reported that he "can't hold together" his thoughts. He indicated chronic sleep impairment and that he worries a great deal about his heart condition and whether he is going to have another heart attack. He used medication for treatment. He worked as a postal clerk and noted a poor relationship with his supervisor and coworkers, and that he took off three months in the previous year for his psychiatric condition. He also reported that he was accused of misappropriating funds in 2004 and although he was found not guilty, he stated that it was difficult to interact with coworkers following this incident as they believed he misappropriated the funds. He was thereafter demoted due to work performance and taking too much time off work. To relieve stress, the Veteran reported that he does not do anything. His wife did all the shopping and housekeeping. He had one friend who he saw occasionally. He further stated that he lost all of his old friends because they think that he stole from the government. Upon examination, the VA examiner reported that the Veteran was a reliable historian. The Veteran was correctly oriented for time, place, person and the purpose of the interview, and that he was clean and neatly and appropriately dressed and groomed. His behavior was appropriate, and related in a somewhat passive dependent manner. Affect was mildly anxious but adequate in range and was appropriate to thought content and mood was mildly anxious. Although impaired impulse control was not apparent on examination, the Veteran reported that it was a problem in his marriages. Speech and communication were normal. However, concentration was impaired, and the Veteran made three errors on serial sevens and did not spell "world" correctly either forwards or backwards. The Veteran did not indicate panic attacks. There was no history of delusions or hallucinations. There were no obsessional rituals, and thought processes were organized and goal directed. Judgment was impaired. The Veteran indicated that when he worked as a postman, he would leave the envelopes lying on the sidewalk rather than put them in a mailbox due to feelings of anxiety. Memory was normal, and there was no evidence of suicidal or homicidal ideation. He had no difficulty at all understanding commands and did not appear to pose any threat of persistent danger or injury to self or others. The examiner determined that the Veteran had occasional interference in performing activities of daily living and that he had difficulty establishing and maintaining effective work and social relationships. His symptoms caused occupational and social impairment including depressed mood, anxiety, and chronic sleep impairment. The examiner diagnosed the Veteran with adjustment disorder with mixed anxiety and depressed mood and assigned a GAF score of 48. The Veteran was afforded a subsequent VA examination in August 2009. He reported that he was depressed and moody. He could not sleep and argued with family members. He also reported lack of interest, fair concentration, crying spells, had feelings of worthlessness, and was retired from the postal office. Upon examination, the VA examiner reported that the Veteran's appearance, psychomotor activity, speech, attitude, affect, attention, orientation, thought process, thought content, judgment, intelligence, insight, hygiene, impulse control, and memory were essentially normal. The examiner noted an absence of delusions, hallucinations, inappropriate behavior, panic attacks, and suicidal and homicidal ideation. However, the Veteran's mood was hopeless and depressed. Furthermore, the examiner noted obsessive/ritualistic behavior, specifically reporting that the Veteran tended to check and recheck too much at home and when he worked. The examiner diagnosed the Veteran with adjustment disorder with depressed mood and assigned a GAF score of 70. The Veteran documented his symptomatology associated with his psychiatric disorder at the February 2011 Board hearing. He testified as to his depression, short-term memory loss, and that he slept with the lights and television on the entire night which caused his wife to sleep in a different room. Furthermore, he stated that his anger problems caused him to "shut down" and become withdrawn. He therefore indicated that he did not have any friends or participate in social activities due to the feelings of withdrawal. The Veteran was provided an additional VA examination on February 4, 2013. He reported that he was recently divorced from his wife, and that he lived in an apartment by himself. He was not in any relationships. He further noted that he feels depressed on a daily basis, and that his only interaction with his children is if they call him when they need something. He also reported crying spells, low interest, energy, and concentration. He also becomes moody and irritable and feels hopeless/helpless at times. He denied suicidal ideation. He reported use of alcohol to fall asleep. Upon examination, the VA examiner pertinently reported that the Veteran's psychiatric symptoms included depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and inability to establish and maintain effective relationships. He indicated that the Veteran's psychiatric disorder was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. He diagnosed the Veteran with depressive disorder, not otherwise specified (NOS) and alcohol abuse and assigned a GAF score of 55. Based on the evidence of record, the Board finds that prior to February 4, 2013, the evidence supports a 50 percent evaluation for the Veteran's service-connected adjustment disorder with anxiety and depression symptoms. Although the Veteran does not have all of the symptomatology consistent with the assignment of a 50 percent rating, for example flattened affect, or circumstantial, circumlocutory, or stereotyped speech, the Board finds that the impact of the Veteran's psychiatric disorder on his social and industrial functioning is sufficient to approximate the degree of impairment contemplated by a 50 percent rating prior to February 4, 2013. See 38 C.F.R. § 4.7 (2012). Criteria for the assignment of a 50 percent rating, which have arguably been met or approximated include impaired judgment, disturbances of motivation and mood, and difficulty in establishing effective work and social relationships. Specifically, a review of the medical evidence indicates that the Veteran's psychiatric symptomatology centers on his difficulty in establishing effective work and social relationships, which is attributed to his depression and other disturbances of motivation and mood; inability to hold his thoughts together; irritability; sleep impairment; and some impairment of memory. These symptoms are more congruent with the assigned 50 percent disability rating. As such, the Board concludes that an increased rating of 50 percent is warranted prior to February 4, 2013. See 38 C.F.R. § 4.7 (2012). With regard to whether the Veteran is entitled to a disability rating in excess of 50 percent prior to February 4, 2013, the Board finds the preponderance of the evidence to be against such. In this regard, the Board notes that the Court of Appeals for the Federal Circuit (Federal Circuit) recently held in Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013) that "in the context of a 70 percent rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." The Board notes that the Veteran had arguably evidenced difficulty adapting to stressful circumstances prior to this date. However, the evidence does not show that the Veteran has occupational and social impairment with reduced reliability and productivity or with deficiencies in most areas prior to February 4, 2013 to warrant a 70 percent disability rating. In this regard, the evidence fails to demonstrate such symptomatology as suicidal ideation; obsessional rituals to the extent that they interfere with routine activities; near-continuous panic or depression; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; neglect of personal appearance and hygiene; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; or other symptoms on par with the level contemplated here. Moreover, although the Board acknowledges that the Veteran has difficulty in establishing effective work and social relationships, the evidence of record shows does not indicate an inability to establish and maintain effective relationships prior to February 4, 2013. Pertinently, he was married at that time, maintained contact with his children, and had a friend he occasionally saw. Furthermore, there are no other factors which would lead the Board to conclude that a 70 percent disability rating is warranted. See Mauerhan v. Principi, supra [the specified factors for each incremental rating are examples rather than requirements for a particular rating; analysis should not be limited solely to whether the claimant exhibited the symptoms listed in the rating scheme]. Rather, the Veteran's level of functioning prior to February 4, 2013 was greater than that contemplated by the 70 percent rating category. However, the Board finds that from February 4, 2013, the Veteran's symptoms worsened and a 70 percent disability rating for his service-connected adjustment disorder with anxiety and depression symptoms is appropriate for this period. The Veteran's reported symptoms from February 4, 2013 include sleep impairment, difficulty adapting to stressful circumstances, difficulty concentrating, anxiety, persistent avoidance of activities and people, feeling hopeless and worthless, depression, obsessive behavior, increased arousal, impaired impulse control, and inability to establish and maintain effective relationships. Moreover, the Board accepts that the Veteran's adjustment disorder with anxiety and depressive symptoms impacts his interpersonal relationships and his employment. Objectively, there is evidence of impaired judgment, difficulty adapting to stressful circumstances, impulsive judgment, and crucially, inability to establish and maintain effective relationships which has resulted in the Veteran's most recent divorce, near absence of communication with his children, and lack of friends. In essence, the evidence reflects symptoms that are best contemplated by the criteria for a 70 percent evaluation in that the Veteran experiences deficiencies in most areas due to those symptoms. The Board has also determined that an evaluation in excess of 70 percent is not warranted for any portion of the appellate period. While the Board accepts that the Veteran's adjustment disorder has significant effects on his functioning, the lay and medical evidence of record does not demonstrate both total occupational and social impairment. While obsessional rituals are arguably evidenced by the record, the evidence does not demonstrate gross impairment in thought process or communication, persistent delusions or hallucinations, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of personal hygiene), disorientation to time or place, or memory loss for names of close relative or own name or other symptoms on a par with the level of severity exemplified in these manifestations. Rather, the Veteran has repeatedly been found to be oriented, maintains normal hygiene, and has not endorsed suicidal or homicidal ideation. There is nothing in the record that supports a finding that the Veteran has symptoms whose severity cause total occupational and social impairment. As such, the Board finds that the record as a whole does not support the existence of symptoms such that there is impairment in reality testing or communications or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood to support an evaluation in excess of 70 percent for adjustment disorder with anxiety and depression symptoms. In summary, the overall disability picture does not more nearly approximate the criteria for a schedular evaluation of 100 percent. Accordingly, the Board concludes that a 50 percent evaluation is warranted for the Veteran's adjustment disorder with anxiety and depression symptoms prior to February 4, 2013, and a 70 percent evaluation is warranted thereafter. See Hart, supra. Hypertension The law and regulations pertaining generally to disability ratings have been set forth above and will not be repeated here. The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007) [holding, "staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings"]. The Veteran essentially contends that his hypertension is more disabling than contemplated by the current noncompensable (zero percent) evaluation. The Veteran's disability has been evaluated under Diagnostic Code 7101 [hypertensive vascular disease (hypertension and isolated systolic hypertension)], which provides for a 60 percent rating for diastolic pressure predominantly 130 or more and a 40 percent disability rating for diastolic pressure is predominantly 120 or more. A 20 percent disability rating is warranted for diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A 10 percent disability rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). The relevant evidence includes VA and private treatment records showing the following blood pressure readings: 120/82 and 120/80 in February 2004, 122/78 in June 2004, 102/70 in July 2004, 116/88 and 124/88 in October 2004, 138/88 in January 2005, 108/68 and 145/90 in February 2005, 106/78 and 122/78 in April 2005, 110/80 in August 2005, 100/78 in February 2006, 100/70 in March 2006, 118/80 in May 2006, 94/72 in June 2006, 110/80 and 114/63 in December 2006, 118/80 in April 2007, 128/88 in May 2007, 120/72 in October 2007, 108/82 in November 2007, 126/86 in February 2008, 124/90 in March 2008, 108/82 and 126/70 in April 2008, 106/80 and 126/70 in April 2008, 110/78 and 106/80 in October 2008, 130/90 and 122/98 in May 2009, 124/88 in December 2009, 130/84 in March 2010, 122/84 in May 2010, 120/90 in July 2010, 124/98 and 132/88 in August 2010, 110/90 and 122/92 as well as 108/96 in January 2011, 122/82 in September 2011, 120/80 in December 2011, 116/84 in May 2012, and 120/92 in December 2012. Additionally, an October 2004 VA examination report noted blood pressure readings of 150/80 and 150/90. A June 2007 VA examination report showed a reading of 134/83. Finally, a February 2013 VA examination report noted readings of 125/82, 110/71, and 108/76. The Board also notes that the Veteran testified at the February 2011 Board hearing that he experiences dizziness and numbness due to his hypertension and uses medication for treatment. Based on review of the evidence, the Board notes that the criteria for a compensable evaluation for hypertension have not been met. The Veteran has not demonstrated diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more. See 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). Specifically, at no point has the Veteran's diastolic pressure been 100 or more. On only two occasions was it close, at 98. Furthermore, at no point was the Veteran's systolic pressure at the 160 level or more. Rather, they were predominantly in the 120s or below. In addition, there is no dispute that the Veteran has required continuous medication for control of his hypertension; however, he has not demonstrated diastolic pressure predominantly 100 or more. See id. Therefore, a compensable evaluation for hypertension is not warranted for any time during the appeal period. See Fenderson, supra. Extraschedular Consideration In evaluating the severity of his service-connected adjustment disorder and hypertension, the Board also has considered whether the Veteran is entitled to a greater level of compensation for the disabilities at issue on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities, with the established criteria shows that the rating criteria reasonably describe the level and symptomatology thereof. The criteria specifically provide for evaluation of the disability based upon the Veteran's symptoms of his service-connected psychiatric disorder and his blood pressure level. They practicably represent the average impairment in earning capacity resulting from the Veteran's service-connected disabilities. See 38 C.F.R. § 4.1. Furthermore, the evidence does not demonstrate marked interference with employment, in excess of the occupational impairment already contemplated by the assigned schedular ratings. Rice consideration In awarding in part and denying in part the Veteran's claims for increased ratings, the Board observes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (Court) held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. As discussed above, the Board has referred the Veteran's TDIU claim for adjudication by the AOJ. Service connection for a low back disability In his original application for compensation benefits received by VA in October 2005, the Veteran alleged that he has a back disability secondary to his service-connected right and left ankle disabilities. He has alternatively stated that the onset of his back disability was in 1989 during military service in Germany when he twisted his back and that he also injured his back in 1990 during service when unloading a vehicle for supplies. He therefore seeks service connection for a back disability on both a direct and secondary basis. Moreover, the record indicates a theory of aggravation of a pre-existing low back disability. The Board will address these contentions below. Aggravation of preexisting disability Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b) (2012). VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See VAOPGCPREC 3-2003 (July 16, 2003); see also Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). The Court has held, however, that this presumption attaches only where there has been an entrance examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). In VAOPGCPREC 3-2003, VA's General Counsel noted that "[u]nder the language of [38 U.S.C. § 1111], VA's burden of showing that the condition was not aggravated by service is conditioned only upon a predicate showing that the condition in question was not noted at entry into service." Cases in which the condition is noted on entrance are, however, still governed by the presumption of aggravation contained in 38 U.S.C. § 1153 (as opposed to that applicable under 38 U.S.C. § 1111 where the complained of condition was not noted on entrance into service). This statute provides that a pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). Aggravation is characterized by an increase in the severity of a disability during service, and a finding of aggravation is not appropriate in cases where the evidence specifically shows that the increase is due to the natural progress of the disease. Furthermore, temporary or intermittent flare-ups of a pre-existing disease during service are not sufficient to be considered aggravation of the disease unless the underlying condition, as contrasted to symptoms, worsens. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991). A pre-existing disease or injury will be presumed to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a) (2012). The Board finds that service connection is not warranted on the basis of aggravation of a pre-existing disability. See 38 U.S.C.A. §§ 1111, 1153; 38 C.F.R. §§ 3.304, 3.306. The Board initially notes that the Veteran's service treatment records are absent a finding of a preexisting low back disability. Although a record documents treatment for low back pain in July 1984 at which time the Veteran was assessed with left buttock muscle strain, there is no indication in the service entrance records of a preexisting low back disability. Therefore, as no back disability was noted at entry, the Veteran is presumed sound. To rebut that presumption, there must be clear and unmistakable evidence that it preexisted and that it was aggravated. In this regard, the Board notes that the Veteran was afforded VA examinations for his low back disability in April 2006 and February 2013 by the same examiner. Pertinently, the examiner considered the Veteran's continuous complaints of back pain as well as his complaint of low back pain in service in July 1984. The examiner also noted the Veteran's report that he twisted his back during service in Germany in 1989 and also injured his back in 1990 when unloading a vehicle for supplies. After examination of the Veteran and consideration of his medical history, the VA examiner concluded in his February 2013 examination report that the Veteran's low back disability clearly and unmistakably preexisted service, as it was congenital. However, he further concluded that it not aggravated beyond its natural progression by his military service. As noted above, the examiner considered the Veteran's in-service treatment complaints of low back pain as well as his reports of injuries to his back in 1989 and 1990. However, he opined that the July 1984 assessment of left buttock strain had "absolutely nothing" to do with the Veteran's lower back. He also noted that the remainder of the Veteran's service treatment records were negative for any complaints of or treatment for a low back disability, and that the evidence of record did not indicate such for many years following the Veteran's discharge from service. Additionally, he discussed the Veteran's report that low back pain was aggravated by post-service employment at the postal service and increase in weight bearing. As such, the examiner opined that the onset of low back pain was many years following the Veteran's discharge from service, and that his current lumbar spine diagnosis and symptoms is more likely related to his postal service employment. The April 2006 and February 2013 VA examination reports were based upon thorough review of the record, thorough examination of the Veteran, and analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) [the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"]. The Board adds that the February 2013 VA examination report is the only medical opinion of record which addresses the matter of aggravation, and that it is not contradicted by the clinical evidence of record. In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). The Board notes that the Veteran has presented no competent clinical evidence of in-service aggravation of a low back disability. The Board finds that the Veteran as a lay person is not competent to associate any of his claimed symptoms to aggravation of a preexisting low back disability. That is, the Veteran is not competent to opine on matters such as aggravation of his low back disability. Such opinion requires specific medical training referable to the orthopedic system and its functionality and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran has the medical training to render medical opinions, the Board must find that his contention with regard to aggravation of his low back disability to be of no probative value. See 38 C.F.R. § 3.159(a)(1) (2012) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. As such, the statements offered by the Veteran in support of his own claim are not competent evidence of aggravation. Accordingly, because the evidence of record indicates that there was clearly and unmistakably no increase in disability during the Veteran's period of active duty service, the Board finds that the presumption of aggravation is not for application. See 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). Direct service connection As stated above, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Specifically, In order to establish service connection for the claimed disorder on a direct basis, there must be (1) 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) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Alternatively, the nexus requirement can be circumvented through operation of the presumption for service connection for chronic diseases, which include arthritis, when manifested to a compensable degree within the initial post-service year. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). The Board initially notes that the record does not reflect medical evidence showing any manifestations of arthritis of the lumbar spine during the one-year presumptive period after the Veteran's separation from service. Indeed, the competent and probative evidence of record does not document a current diagnosis of arthritis of the lumbar spine. Notably, the VA examiner specifically reported in the February 2013 examination report that arthritis was not identified based on review of X-ray of the Veteran's lumbar spine. Furthermore, the record does not reflect any complaints or findings of a low back disability until 2005 (more than 10 years after his separation from active service). Accordingly, service connection is not warranted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. With respect to element (1), current disability, the competent medical evidence of record indicates diagnosis of rightward curvature structure degenerative lumbar spine with Grade 1 anterolisthesis of L5 on S1. See, e.g., the February 2013 VA examination report. Accordingly, element (1), current disability, is satisfied. Turning to Hickson element (2), in-service incurrence of an injury or disease, as discussed above, the Veteran's service treatment records document treatment for low back pain in July 1984, thus arguably satisfying the element. At that time, the Veteran was assessed with left buttock muscle strain, which current medical evidence has established was not due to back pain. The remainder of the Veteran's service treatment records, to include his July 1992 separation examination, is absent complaints of or treatment for a low back disability. Regardless, the Board again notes that the Veteran has reported that he twisted his back during service in Germany in 1989 and also injured his back in 1990 when unloading a vehicle for supplies. See the February 2013 VA examination report. He further reported that he did not receive treatment for either of these injuries. He is competent to report his experiences. Turning to crucial element (3), nexus, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the competent and probative evidence of record is against a finding that the Veteran's current low back disability is related to his military service. As discussed above, the Veteran was afforded VA examinations in April 2006 and February 2013 by the same examiner. Pertinently, the examiner considered the Veteran's continuous complaints of back pain as well as his complaint of low back pain in service in July 1984 and back injuries in 1989 and 1990. After examination of the Veteran and consideration of his medical history, the VA examiner concluded that the Veteran's current low back disability does not have any relationship to his active duty service. The examiner's rationale for his conclusion was based on his review of the Veteran's service treatment records and his finding that the July 1984 assessment of left buttock strain had "absolutely nothing" to do with the Veteran's lower back. He also noted that the remainder of the Veteran's service treatment records were negative for any complaints of or treatment for a low back disability, and that the evidence of record did not indicate such for many years following the Veteran's discharge from service. Moreover, he discussed the Veteran's post-service employment as a postman and the Veteran's report that low back pain was aggravated by work and increase in weight bearing. Indeed, the examiner opined that the onset of low back pain was many years following the Veteran's discharge from service, and that his current lumbar spine diagnosis and symptoms is more likely related to his postal service employment. The April 2006 and February 2013 VA examination reports were based upon thorough review of the record, thorough examination of the Veteran, and analysis of the Veteran's entire history. See Bloom, supra. Additionally, the VA examiner's opinion is consistent with the Veteran's documented medical history, which is absent any report of symptomatology of a low back disability for more than 10 years after service. The Veteran has not submitted a competent medical opinion to contradict the VA examiner's opinion. As was explained in the VCAA section above, the Veteran has been accorded ample opportunity to present competent medical evidence in support of his claim. He has failed to do so. See 38 U.S.C.A. § 5107(a) (West 2002) [it is the claimant's responsibility to support a claim for VA benefits]. In short, the Board finds the above cited opinion to be highly probative of the issue of nexus. The Board notes that the Veteran, while entirely competent to report his symptoms both current and past (including low back pain), has presented no competent evidence of a nexus between his low back disability and his military service. The Board finds that the Veteran as a lay person is not competent to associate any of his claimed symptoms to his military service. That is, the Veteran is not competent to opine on matters such as the etiology of his current low back disability. Such opinion requires specific medical training referable to the orthopedic system and its functionality and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran has the medical training to render medical opinions, the Board must find that his contention with regard to a nexus between his low back disability and military service to be of no probative value. See 38 C.F.R. § 3.159(a)(1), supra. Accordingly, the statements offered by the Veteran in support of his own claim are not competent evidence of a nexus. To the extent that the Veteran has asserted that he has had a low back disability continually since service, the Board notes that it is aware of the provisions of 38 C.F.R. § 3.303(b), relating to chronicity and continuity of symptomatology in establishing service connection. However, the Federal Circuit has held that section 3.303(b) applies only to those chronic conditions specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Although arthritis is included in this list, as discussed above, the competent and probative evidence of record does not indicate that the Veteran suffers from arthritis of the lumbar spine. Therefore, establishment of service connection on the basis of continuity of symptomatology is not warranted. Based on the foregoing, the Board concludes that element (3), nexus, is not met. Accordingly, the Veteran's claim fails on this basis. Secondary service connection Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a) (2012); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). With respect to element (1), current disability, as discussed above, the competent medical evidence of record indicates diagnosis of rightward curvature structure degenerative lumbar spine with Grade 1 anterolisthesis of L5 on S1. See, e.g., the February 2013 VA examination report. Accordingly, element (1), current disability, is satisfied. Wallin element (2) has been met; the Veteran is service-connected for right and left ankle disabilities. Turning to crucial element (3), nexus, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the competent and probative evidence of record is against a finding that the Veteran's current low back disability is related to his service-connected right and left ankle disabilities. With regard to whether the Veteran's low back disability is related to his service-connected right and left ankle disabilities, the VA examiner indicated in his April 2006 and February 2013 examination reports that the Veteran's low back disability is not related to or aggravated by the right and left ankle disabilities. The examiner's rationale for his conclusion was based on his finding that the Veteran evidenced a normal gait. He also noted the Veteran's diagnosis of lumbar spondylosis, which he reported is a bony defect in the pars interarticularis of the vertebral arch. He further reported that it presents a weakness or stress fracture in one of the bony bridges that connects the upper with the lower facet joints. The defect could either be symptomatic or associated with significant low back pain. Although the examiner reported that the etiology of the lesion is unclear, it has an increased prevalence in men, particularly those who engage in activities that appear to put unusual stress on their spine. He also reported that the ankle mortise controls the motion of the ankle and is susceptible to ankle strains and sprains. However, the ankle has no control of back spinal muscle, anatomy, or function. He therefore indicated no causation or aggravation of the Veteran's low back disability by his right and left ankle disabilities. The April 2006 and February 2013 VA examination reports were based upon thorough review of the record, thorough examination of the Veteran, and analysis of the Veteran's entire history. See Bloom, supra. The Veteran has not submitted a competent medical opinion to contradict the VA examiner's opinion. As was explained in the VCAA section above, the Veteran has been accorded ample opportunity to present competent medical evidence in support of his claim. He has failed to do so. See 38 U.S.C.A. § 5107(a) (West 2002) [it is the claimant's responsibility to support a claim for VA benefits]. In short, the Board finds the above cited opinion to be highly probative of the issue of nexus. The Board notes that the Veteran, while entirely competent to report his symptoms both current and past (including low back pain), has presented no competent evidence of a nexus between his low back disability and his service-connected right and left ankle disabilities. The Board finds that the Veteran as a lay person is not competent to associate any of his claimed symptoms to his service-connected right and left ankle disabilities. That is, the Veteran is not competent to opine on matters such as the etiology of his current low back disability. Such opinion requires specific medical training referable to the orthopedic system and its functionality and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran has the medical training to render medical opinions, the Board must find that his contention with regard to a nexus between his low back disability and his right and left ankle disabilities to be of no probative value. See 38 C.F.R. § 3.159(a)(1), supra. Accordingly, the statements offered by the Veteran in support of his own claim are not competent evidence of a nexus. Based on the foregoing, the Board concludes that element (3), nexus, is not met. As such, the Veteran's claim fails on this basis. Conclusion In conclusion, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a low back disability, to include as secondary to service-connected right and left ankle disabilities. The benefit sought on appeal is accordingly denied. (CONTINUED ON NEXT PAGE) ORDER Prior to February 4, 2013, entitlement to a 50 percent disability rating for adjustment disorder with anxiety and depression symptoms is granted, subject to controlling regulations applicable to the payment of monetary benefits. From February 4, 2013, entitlement to a 70 percent disability rating for adjustment disorder with anxiety and depression symptoms is granted, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to an initial compensable rating for hypertension is denied. Entitlement to service connection for a low back disability, to include as secondary to service-connected residuals of right and left ankle sprains is denied. ____________________________________________ Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs