Citation Nr: 1334498 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 10-06 597 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for a left knee disorder. 3. Entitlement to an initial rating in excess of 50 percent for sinusitis. 4. Entitlement to an initial rating in excess of 10 percent for residuals of a right ankle sprain. ATTORNEY FOR THE BOARD A. Zenzano, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1994 to January 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which, in pertinent part, denied service connection for hypertension and a left knee disorder, and granted service connection for sinusitis and residuals of a right ankle sprain, assigning 10 percent and noncompensable (0 percent) ratings, respectively, effective October 16, 2006. In a February 2013 rating decision, the RO granted an initial 50 percent rating for sinusitis and a 10 percent rating for residuals of a right ankle sprain, effective October 16, 2006. Despite the higher initial ratings established, the Veteran has not been awarded the highest possible ratings. As a result, he is presumed to be seeking the maximum possible benefit and his claims remain in appellate status. A.B. v. Brown, 6 Vet. App. 35 (1993). The Board notes that the June 2008 rating decision also denied service connection for back strain, hip pain, migraine headaches, tinea versicolor, skin rash, athlete's foot, and cervical spine injury. The Veteran entered a notice of disagreement as to such denials in September 2008 and a statement of the case was issued in December 2009. However, in the Veteran's February 2010 substantive appeal (VA Form 9), he specifically limited his appeal to the issues shown on the title page. Therefore, as he has not submitted a timely substantive appeal as to the issues of entitlement to service connection for back strain, hip pain, migraine headaches, tinea versicolor, skin rash, athlete's foot, and cervical spine injury, such issues are not before the Board. The Board observes that a September 2012 rating decision denied service connection for a chronic adjustment disorder. In October 2012, the Veteran entered a notice of disagreement as to such denial and a statement of the case was issued in March 2013. However, the Veteran did not submit a timely substantive appeal. Therefore, such issue is not before the Board. The Board further notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the Virtual VA claims file reveals additional VA treatment records dated to November 2012, which were considered by the agency of original jurisdiction (AOJ) in the November 2012 supplemental statement of the case. While Virtual VA also contains April 2013 VA treatment records, the Board finds that, as relevant to the Veteran's left knee and right ankle claims, such are irrelevant or duplicative of the evidence already considered by the AOJ. In this regard, an April 2013 VA treatment record reflects that the Veteran requested a refill on his pain medication for his right ankle and had minimal swelling on examination. Such findings are documented in previous VA treatment records and VA examination reports. Furthermore, to the extent that the April 2013 VA treatment records pertain to the Veteran's sinusitis and hypertension, as such claim is being remanded the AOJ will have an opportunity to review the new documents such that no prejudice results to the Veteran in the Board considering such evidence for the limited purpose of issuing a comprehensive and thorough remand. The issues of entitlement to service connection for hypertension and entitlement to an initial rating in excess of 50 percent for sinusitis are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. A left knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service. 2. For the entire appeal period, the Veteran's residuals of a right ankle sprain have been manifested by pain, instability, tenderness, and, at most, moderate limitation of motion, without marked limitation of motion, ankylosis, malunion of the os calcis or astragalus, or astragalectomy. CONCLUSIONS OF LAW 1. A left knee disorder was not incurred in or aggravated by the Veteran's active duty military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. For the entire appeal period, the criteria for an initial rating in excess of 10 percent for residuals of a right ankle sprain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the AOJ. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Regarding the Veteran's service connection claim for a left knee disorder, he was sent letters in November 2006 and April 2008, which were prior to the issuance of the initial RO decision in this matter. The letters provided information as to what evidence was required to substantiate his service connection claim and of the division of responsibilities between VA and a claimant in developing such evidence. Such letters also informed the Veteran of what type of information and evidence was needed to establish disability ratings and effective dates in accordance with Dingess/Hartman, supra. Accordingly, VA has satisfied its duty to notify under the VCAA regarding this issue. With respect to the Veteran's residuals of a right ankle sprain, the Board observes that he has appealed the initially assigned rating from the original grant of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claim for service connection for his residuals of a right ankle sprain was granted and an initial rating was assigned in the June 2008 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains service treatment and personnel records, as well as post-service reports of VA and private treatment. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. Additionally, the Veteran was afforded VA examinations in April 2011 and September 2011, performed by the same physician, to ascertain the etiology of his left knee disorder. The Board finds these examination reports adequate to decide the issue. Although the claims file was not available for review during the April 2011 VA examination, a medical history was taken and a physical examination was conducted. An examination is not rendered inadequate merely because the claims file was not reviewed. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008). Moreover, the physician provided a rationale for his opinion and, in September 2011, re-examined the Veteran, with review of the claims file. The opinion offered in September 2011 considered the full record, to include the Veteran's service treatment records, lay statements, and current medical condition. The VA examiner considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided an opinion supported by a complete rationale, relying on, and citing to, the records reviewed. Moreover, the expert offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the service connection issue decided herein has been met. In April 2012, the Veteran underwent a VA examination to address the severity of his right ankle disability. He has not alleged that such is inadequate for rating purposes. Moreover, the Board finds that the examination is adequate in order to evaluate the Veteran's service-connected residuals of a right ankle sprain as it includes an interview with the Veteran, a review of the pertinent medical history, and a full physical examination, addressing the relevant rating criteria. The Board notes that the Veteran has not alleged worsening since the April 2012 VA examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (mere passage of time not a basis for requiring of new examination). Therefore, the Board finds that the examination report of record is adequate to adjudicate the Veteran's initial rating claim and no further examination is necessary. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service Connection The Veteran seeks service connection for a left knee disorder, which he asserts is due a motor vehicle accident in which his knee was injured, and a subsequent hyperextension of the knee during physical training. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Medical evidence shows that the Veteran suffered an in-service left knee injury, and that he has a current diagnosis of left knee strain. As there is no evidence of left knee arthritis, the Veteran's service connection claim may not be substantiated on a presumptive basis through showing manifestation within one year of service separation or continuity of symptomatology. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. Moreover, as relevant to direct service connection, as explained below, as there is no competent evidence of record suggesting a link between the Veteran's left knee disorder and service, service connection is not warranted. In this regard, service treatment records reflect that the Veteran suffered an in-service motor vehicle accident, sustaining a left knee contusion in November 1994. X-rays were taken, and the Veteran was diagnosed with a knee sprain and placed on light duty. In medical histories completed in August 1998 and October 1998, the Veteran reported a positive history of left knee pain. An August 1998 examination indicates the Veteran's lower extremities were clinically normal. Post-service, a March 2009 VA X-ray report, ordered in response to the Veteran's reports of chronic knee pain, shows a normal left knee. A June 2010 private treatment note shows that a left knee X-ray was again unremarkable, but shows a possible medial meniscal tear of the left knee. In April 2011, the Veteran underwent a VA examination. The claims file was not available for review, but the Veteran told the examiner of his in-service car accident that injured his knee, and his subsequent hyperextension of the knee. He reported that he was placed on light duty for three weeks twice during service, and that he has worn a brace since 1997. The Veteran reported that his knee gives out on him at least two days a week and that his pain can reach 10/10, but that he has never had any incapacitation. Physical examination revealed no abnormalities, with the exception of a mild spasm noted throughout range of motion testing. X-ray reports showed a normal left knee. The Veteran was diagnosed with a chronic left knee strain. The examiner opined that the Veteran's left knee disorder was less likely as not related to his in-service knee injuries, as the Veteran, "did not have any history of surgery, no fracture, no dislocation, and the condition is usually a self limiting problem." In September 2011, the Veteran underwent another examination by the same physician who conducted the April 2011 examination. The Veteran alleged that his knee pain has been constant since service. Physical examination of the knee was unremarkable; repetitive examination did not yield any spasm. The previous diagnosis of left knee strain remained unchanged. The VA examiner noted review of the Veteran's claims file, and recounted his pertinent medical history, again finding that his left knee disorder was less than likely related to service. He reasoned that the Veteran's knee was only sprained during service, and the August 1998 examination was negative for any left knee condition. The Board accords the VA examiner's August 2011 and September 2011 opinions significant probative value on the question of etiology, as they are based on a full understanding of the Veteran's medical history (as well as a thorough review of the Veteran's medical records in September 2011) and include a rationale that discusses the Veteran's pertinent medical history. See Nieves, supra. Furthermore, the examiner offered clear conclusions with supporting data and reasoned medical explanations. Id., Stefl, supra. There is no contrary competent evidence or opinion of record to refute the VA examiner's opinions, and the Veteran has not identified an existing opinion by a competent professional to support the claim. The Board has considered the lay statements of record from the Veteran which attribute his left knee disorder to service. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but are not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-470 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's current left knee disorder and any instance of his military service to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In this regard, the Board finds that the etiology of the Veteran's left knee disorder is a complex medical question. Specifically, the question of causation of a knee disorder, to include a strain, involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. There is no indication that the Veteran possesses such requisite knowledge, and, therefore, he is not competent to render an opinion on such a complex medical question. Thus, the Board accords these statements regarding the etiology of such disorder little probative value as the Veteran is not competent to opine on such complex medical questions. Moreover, he has offered only conclusory statements regarding the relationship between his military service and his current left knee strain. Waters, supra. In contrast, the April 2011/September 2011 VA examiner took into consideration all of the relevant facts in providing an opinion, to include the Veteran's service treatment records, post-service treatment, and the current nature of his left knee strain. Consequently, the Board accords greater probative weight to the VA examiner's opinion. Based on the foregoing, the claim for service connection for a left knee disorder must be denied. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. III. Increased Rating The Veteran contends that he is entitled to a higher disability rating for residuals of a right ankle sprain. Such disability has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271, as 10 percent disabling, effective October 16, 2006. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155 ; 38 C.F.R. § 4.1. 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. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same disability which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." 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. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. Under Diagnostic Code 5271, ankle disability with moderate limitation of motion warrants a 10 percent rating. A 20 percent rating is assigned for ankle disability with marked limitation of motion. Id., DC 5271. Standard range of ankle dorsiflexion is from 0 to 20 degrees, and plantar flexion from 0 to 45 degrees. See 38 C.F.R. § 4.71, Plate II. The terms "slight," "moderate," and "marked" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just," and all evidence must be evaluated in deciding rating claims. 38 C.F.R. § 4.6. Private treatment notes show that the Veteran denied joint pain in April 2009. A September 2009 private treatment note documents treatment for a right ankle sprain. The Veteran admitted joint pain. Physical examination revealed that the Veteran had some tenderness around the lateral malleolus right ankle with no deformity and no discoloration. Minimal swelling and good range of motion were noted. The Veteran had some discomfort when his talofibular ligament was stretched. X-rays revealed no acute injuries. Private treatment notes further show that the Veteran denied joint pain in April 2009, November 2009, December 2009 and January 2010. In June 2010, the Veteran sought treatment for right ankle pain and instability. It was noted that he was previously counseled on ligament reconstruction for his ankle. Physical examination of the right ankle revealed mild swelling laterally, and it was tender to palpation. His ankle had full range of motion, and an X-ray showed evidence of a previous deltoid ligament injury, but was otherwise unremarkable. The Veteran again denied joint pain in September 2010, October 2010, and November 2010 private treatment notes. In April 2011, the Veteran underwent a VA examination. At such time, he reported that his right ankle disability limits everything he does, including only being able to stand for 20 minutes. He also reported missing 20 days of work in the past year due to, in part, his ankle problems. Physical examination of his right ankle revealed a normal shape, plantar flexion to 20 degrees and dorsiflexion to 10 degrees. Repetitive activity did not yield any changes, but muscle spasm was present. X-rays revealed a normal right ankle, with no significant osseous, articular or soft tissue abnormality. In April 2012, the Veteran underwent another VA examination for his right ankle. He reported flare-ups occurring approximately twice a month, along with swelling, pain and an inability to bear weight. Range of motion testing revealed plantar flexion to 40 degrees, with pain at 35 degrees and dorsiflexion to 15 degrees, with pain at 10 degrees. The Veteran was able to perform repetitive-use testing, with no additional limitations in range of motion. He reported functional impairment, manifested by less movement, weakened movement, swelling, instability and interference with sitting, standing and weight-bearing. Pain on palpation of the right ankle was present. Findings were negative for ankylosis, shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), nor has the Veteran had a talectomy (astragalectomy). The Veteran reported that he has not had ankle surgery, but he uses a brace. X-rays revealed no abnormal findings. The Veteran reported that his ankle disability impacts his ability to work because he has to sit and rest approximately every 30 minutes due to the pain. Considering the pertinent evidence in light of the above, the Board finds that a rating in excess of 10 percent for the Veteran's residuals of a right ankle sprain is not warranted. A higher rating for limitation of motion of the ankle pursuant to Diagnostic Code 5271 requires marked limitation of motion. See 38 C.F.R. § 4.71a. In this case, the evidence shows that the Veteran's range of motion for his ankle traversed the spectrum from "full" to, at its most restricted, dorsiflexion to 10 degrees and plantar flexion to 20 degrees, which still allows for much movement of the ankle. Thus, the medical evidence documents that the service-connected residuals of a right ankle sprain are productive of, at most, moderate limitation of motion of the ankle under Diagnostic Code 5271. The Board has considered additional loss of function per 38 C.F.R. §§ 4.40 and 4.45, Mitchell, supra, and DeLuca, supra. The Veteran's additional symptoms include pain, tenderness, instability and difficulty bearing weight. Objective evidence shows that, on multiple occasions, the Veteran denied joint pain. The Board acknowledges that, at his April 2012 VA examination, the Veteran functional impairment, manifested by less movement, weakened movement, swelling, instability and interference with sitting, standing and weight-bearing. However, such did not result in functional loss that more nearly approximates marked limitation of ankle motion. Specifically, at such time, examination revealed plantar flexion to 40 degrees, with pain at 35 degrees and dorsiflexion to 15 degrees, with pain at 10 degrees. Moreover, the Veteran was able to perform repetitive-use testing, with no additional limitations in range of motion. Furthermore, private medical records show that, on multiple occasions, the Veteran denied joint pain. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). Based on such denials of pain and the objective evidence demonstrating that the Veteran's additional symptoms do not result in functional loss, the Board finds that the evidence of record does not show additional functional limitation due to these symptoms that is tantamount to the marked degree of limitation required to achieve the higher 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5271. As such, a higher evaluation based on limitation of motion is not warranted. Id. The Board has also considered the applicability of other, potentially applicable diagnostic criteria for rating the Veteran's right ankle disability, but finds that no higher rating is assignable any other diagnostic code. There is no competent evidence of record documenting the presence of any ankylosis in the ankle or its equivalent so an increased or separate rating is not warranted under Diagnostic Codes 5270 or 5272. Also, as there is no competent evidence demonstrating that the service-connected disability is manifested by malunion of the os calcis or astragalus, or astragalectomy. Therefore, Diagnostic Codes 5273 are 5274, respectively, are inapplicable. See 38 C.F.R. § 4.71a. Furthermore, the right ankle disability also has not been shown to involve any other factor(s) warranting evaluation under any other provision(s) of VA's rating schedule. Additionally, the Board has considered the Veteran's statements that a higher disability rating is warranted for his residuals of a right ankle sprain. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptomatology relating to his residuals of a right ankle sprain because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability relating such to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's disability has been provided by the VA examiners who examined him during the current appeal and who have provided relevant medical findings in conjunction with the examinations. In this regard, the medical findings (as provided in the examination reports) directly address the criteria under which his disability is evaluated. The Board concludes that the medical findings on examination are of greater probative value than the Veteran's allegations regarding the severity of his residuals of a right ankle sprain. Accordingly, entitlement to an initial rating in excess of 10 percent for the Veteran's service-connected residuals of a right ankle sprain must be denied. In so finding, the Board adds that there is no evidence that this disability has exceeded the current rating assigned at any time during the period on appeal. Therefore, there is no basis for any staged rating. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 extra-schedular rating. Id. Here, the Board finds that the Veteran's residuals of a right ankle sprain are fully addressed by the rating criteria under which such disability is rated. Specifically, the Veteran's 10 percent rating contemplates his complaints of pain and limitation of motion, as well as his functional impairment resulting from such. Therefore, there are no additional symptoms of the Veteran's residuals of a right ankle sprain that are not addressed by the rating schedule. Accordingly, the Board finds that the rating criteria reasonably describes the Veteran's disability level and symptomatology of his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Hence, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a total disability rating based on individual unemployability (TDIU) will be considered "part and parcel" of the claim for benefits for the underlying disability. In the instant case, though the Veteran has reported impairment with his work due to residuals of a right ankle sprain, he has not alleged, and the evidence does not show, that such renders him unemployable. Moreover, such impairment at work is contemplated by his assigned 10 percent rating. Therefore, the issue of a TDIU has not been raised and no further consideration of such is necessary. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to an initial rating in excess of 10 percent for a right ankle sprain. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for a left knee disorder is denied. An initial rating in excess of 10 percent for residuals of a right ankle sprain is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Regarding hypertension, the Veteran claims that such had its onset during service. For VA purposes, hypertension is defined as diastolic blood pressure predominantly 90mm or greater, and isolated systolic hypertension means systolic blood pressure that is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. 38 CFR § 4.104, Note (1). Here, an August 1993 enlistment examination shows that the Veteran entered service with a blood pressure reading of 114/62. Blood pressure readings taken during service fall in the normal range, but are on the higher side. A blood pressure reading, taken toward the end of the Veteran's service, in September 1998, shows 130/92. The Veteran has alleged that he was told in service that his blood pressure needed to be watched, as it was on the high side, and that it has continued to increase. See December 2006 statement. Treatment records reflect that he currently takes Lisinopril for hypertension. Accordingly, a VA examination is warranted to determine whether the Veteran's current hypertension is related to his military service, to include his elevated blood pressure readings. With respect to the Veteran's claim for a higher initial rating for his sinusitis, the Board notes that relevant VA treatment notes were recently added to the Veteran's Virtual VA file. These records have not been considered by the AOJ; nor has the Veteran waived initial review by the AOJ. Therefore, a remand is necessary in order to allow AOJ review of such additional evidence. Moreover, these records indicate that the Veteran continues to receive private treatment for his sinusitis from Dr. Charleton, of Enterprise, Alabama, as recently as April 2013. See April 2013 VA treatment note. Therefore, the Veteran should be provided with an opportunity to identify any VA or non-VA healthcare providers who have treated him for his sinusitis and, thereafter, all identified records, to include those from Dr. Charleton, should be obtained for consideration in his appeal. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran provide or identify any VA or non-VA medical records pertaining to his sinusitis that are not already associated with the claims folder. After obtaining any necessary authorization forms, obtain all identified records, to include those from Dr. Charlton of Enterprise, Alabama. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e) . 2. Schedule the Veteran for a VA examination to ascertain the nature and etiology of his hypertension. The claims folder and a copy of this Remand must be made available to the examiner. The examiner should note in the examination report that the claims folder has been reviewed. Any appropriate evaluations, studies, and testing deemed necessary by the examiner should be conducted at this time, and included in the examination report. Thereafter, the examiner should offer opinions on the following: (a) Is it at least as likely as not that the Veteran's current hypertension began in or is otherwise is related to service, to include his elevated blood pressure readings? (b) Is it at least as likely as not that the Veteran's hypertension manifested within one year of his service discharge in January 1999? If so, what were the manifestations? A complete rationale must be provided for all opinions. In offering such opinions, the examiner should consider the full record, to include the Veteran's lay statements regarding service incurrence and continuity of symptomatology. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs