Citation Nr: 1338121 Decision Date: 11/20/13 Archive Date: 12/06/13 DOCKET NO. 05-28 875 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California THE ISSUES 1. Entitlement to an increased disability rating for right knee arthritis, rated at 20 percent prior to July 14, 2010, 100 percent from July 14, 2010 to September 1, 2011, and 30 percent since September 1, 2011. 2. Entitlement to an increased disability rating for left knee arthritis, rated at 10 percent. 3. Entitlement to service connection for a left ankle disability, to include as secondary to a service-connected knee disability. 4. Entitlement to service connection for a right elbow disability, to include as secondary to a service-connected knee disability. 5. Entitlement to service connection for post-traumatic stress disorder (PTSD). 6. Entitlement to service connection for an acquired psychiatric disability other than PTSD. REPRESENTATION Appellant (the Veteran) is represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from July 1981 to August 1983. This appeal comes before the Board of Veterans' Appeals (Board) from a July 2004 rating decision of the RO in Los Angeles, California. The Veteran did not report for a Board hearing that was scheduled to be conducted at the RO in March 2013. To the Board's knowledge, the Veteran has offered no explanation as to why she was unable to appear for the scheduled hearing and she has since made no request for another hearing. Accordingly, the Board will proceed to a decision on this appeal as if the hearing request had been withdrawn. See 38 C.F.R. § 20.704(d) (2013). In February 2009, the Board remanded this appeal for additional evidentiary development. The requested development has since been completed and the case has been returned to the Board for further appellate action. In reviewing this case the Board has not only reviewed the physical claims file, but has also reviewed the electronic file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's right knee disability has been manifested by arthritis with painful and weak motion; flexion has been demonstrated to at least 60 degrees; prior to April 28, 2010, right knee extension was limited at most to 2 degrees; from April 28, 2010 to July 14, 2010, right knee extension was limited to 15 degrees; prior to July 14, 2010, the Veteran's right knee disability was also manifested by lateral instability or recurrent subluxation that was no more than moderate; a temporary total rating is in effect for the right knee from July 14, 2010 to September 1, 2011; since September 1, 2011, the Veteran's right knee disability has been manifested by a prosthetic knee replacement with range of motion that is noncompensable and that is not severely painful or weak. 2. For the entire period of this appeal, the Veteran's left knee disability has been manifested by arthritis with pain and weakness; flexion has been demonstrated to at least 60 degrees, and extension has been limited at most to 0 degrees; there was no lateral instability or recurrent subluxation. 3. The evidence relating the Veteran's current left ankle arthritis to her service-connected knee disabilities is in relative equipoise with the evidence against this relationship. 4. The Veteran does not have a current disability of the right elbow. 5. The Veteran's account of PTSD stressors is materially inaccurate; there is no verified PTSD stressor and additional development to verify a PTSD stressor is not warranted. The Veteran's own prior credible statements provide evidence against this claim. 6. A psychosis did not become manifest to a compensable degree within 1 year of service separation; symptomatology of a psychosis was not continuous after service; an acquired psychiatric disability other than PTSD is not related to service. CONCLUSIONS OF LAW 1. Prior to April 28, 2010, the criteria for a separate 10 percent disability rating for right knee arthritis were met; the criteria for a disability rating in excess of 10 percent for right knee arthritis were not met for any portion of that period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2013). 2. From April 28, 2010 to July 14, 2010, the criteria for a separate 20 percent rating for right knee arthritis were met; the criteria for a rating in excess of 20 percent for right knee arthritis were not met for any portion of that period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2013). 3. Prior to July 14, 2010, the criteria for a rating in excess of 20 percent for right knee subluxation or lateral instability were not met for any portion of that period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 5257 (2013). 4. Since September 1, 2011, the criteria for a rating in excess of 30 percent for prosthetic right knee replacement are not met for any portion of that period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 5055, 5256, 5260, 5261 (2013). 5. The criteria for a rating in excess of 10 percent for a left knee disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5260, 5261 (2013). 6. A left ankle disability is proximately due to or a result of a service-connected disability. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2013). 7. The basic criteria for service connection for a right elbow disability are not met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 8. PTSD was not incurred in service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 9. An acquired psychiatric disability other than PTSD was not incurred in service; a psychosis is not presumed to have been incurred in service. 38 U.S.C.A. §§ 337, 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Knee Disability Ratings In a September 1992 rating decision, the RO granted service connection for "right knee injury with degenerative changes" and assigned a disability rating of 10 percent pursuant to Diagnostic Code 5257, effective January 18, 1992. In an October 1997 rating decision, the RO made retroactive changes to the rating assignments. The RO assigned a temporary 100 percent rating for surgical convalescence for the right knee, pursuant to 38 C.F.R. § 4.30, effective July 1, 1992 to July 1, 1992, assigned a 10 percent rating pursuant to Diagnostic Code 5257 from July 1, 1992 to July 29, 1993, assigned a 20 percent rating pursuant to Diagnostic Code 5257 from July 29, 1993 to September 20, 1995, assigned a temporary 100 percent rating based on surgical convalescence pursuant to 38 C.F.R. § 4.30 from September 20, 1995 to December 1, 1995, and assigned a 20 percent rating pursuant to Diagnostic Code 5257, effective December 1, 1995. In a March 1999 decision, the Board granted an extension of the temporary total rating for surgical convalescence from December 1, 1995 to April 1, 1996. This current appeal arises from a claim received at the RO on September 26, 2002. In the July 2004 rating decision, the RO denied an increased rating for the right knee. In a July 2010 rating decision, the RO granted a temporary 100 percent rating for the right knee based on surgical convalescence pursuant to 38 C.F.R. § 4.30 from July 14, 2010 to September 1, 2011. A 30 percent rating was assigned for right knee prosthesis pursuant to Diagnostic Code 5055, effective September 1, 2011. In the October 1997 rating decision noted above, the RO also granted service connection for a left knee disability and assigned a 10 percent rating pursuant to Diagnostic Code 5257, effective July 29, 1993. As to the left knee, the current appeal also arises from a claim received at the RO on September 26, 2002. In the July 2004 rating decision, the RO, without explanation, changed the diagnostic code for the left knee from 5257 to 5010, but did not change the disability rating assigned. Diagnostic Code 5010 is used to rate the condition arthritis due to trauma, but simply directs to rate the condition in accordance with degenerative arthritis (Diagnostic Code 5003), which in turn rates on the basis of limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Diagnostic Code 5055 governs prosthetic replacement of the knee joint. Under that code, a 100 percent rating is for assignment for 1 year following implantation of the prosthesis, such as was done in this case. After that period, a 60 percent rating requires chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, the disability is to be rated by analogy to diagnostic codes 5256, 5261, or 5262 with a minimum rating of 30 percent. Ratings for limitation of knee motion are addressed by Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 addresses limitation of flexion of the knee. Under that code, a 30 percent rating is for application were flexion is limited to 15 degrees; a 20 percent rating is for application where flexion is limited to 30 degrees; a 10 percent rating is for application where flexion is limited to 45 degrees; a 0 percent rating is for application where flexion limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 addresses limitation of extension of the knee. Under that code, a 50 percent rating is for application where extension is limited to 45 degrees; a 40 percent rating is for application where extension is limited to 30 degrees; a 30 percent rating is for application where extension is limited to 20 degrees; a 20 percent rating is for application where extension is limited to 15 degrees; a 10 percent rating is for application where extension is limited to 10 degrees; a 0 percent rating is for application where extension is limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Diagnostic Code 5256 governs ankylosis (complete bony fixation) of the knee, which is neither asserted nor shown here with respect to either knee. Diagnostic Code 5257 addresses recurrent subluxation or lateral instability of the knee. Under that code, a 30 percent rating is for application where subluxation or lateral instability is severe. A 20 percent rating is for application where subluxation or lateral instability is moderate. A 10 percent rating is for application where subluxation or lateral instability is slight. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board notes that the criteria under Diagnostic Codes 5257, 5260, and 5261 are not considered to be overlapping, and therefore separate ratings can be assigned where appropriate symptomatology is shown. In this case, prior to the prosthetic knee replacement, the Veteran's right knee had consistently been rated under Diagnostic Code 5257 for subluxation or lateral instability. However, the grant of service connection for the right knee specifically included degenerative joint disease (arthritis). Moreover, as will be addressed in more detail below, the Veteran has consistently reported painful and limited motion of the right knee. As Diagnostic Code 5257 does not contemplate limitation of motion, based on separate and non-overlapping symptomatology, the Board finds that a separate compensable rating under Diagnostic Code 5010-5003 for arthritis and limited flexion of the right knee was warranted for the period prior to the prosthetic knee replacement, excluding periods when temporary total ratings were applied. However, effective September 1, 2011, there has been a prosthetic knee replacement. The rating assigned under Diagnostic Code 5055 contemplates limited motion, as well as the Veteran's other knee symptoms. Thus, in addition to ratings under Diagnostic Codes 5255 and 5257, the Board will consider the appropriate ratings for limitation of motion. The report of VA examination in December 2002 reveals active range of motion of the right knee from 0 degrees (reported as 180 degrees) to 100 degrees, and from 0 to 120 degrees on the left. There was no abnormality of strength, and no awkward, slowed, or incoordinated motion. Imbalance secondary to early fatiguability was not likely. There was essentially normal strength, although diminished on the right at 4/5. Muscle strength testing in a September 2002 physical therapy note revealed findings of 4-/5 on the left and 4/5 on the right. The report of VA examination in July 2003 reveals that flexion of the right knee was limited to 100 degrees and pain occurred at 100 degrees. Extension was not limited and did not produce pain. In the left knee, there was no limitation of motion, but pain occurred at 140 degrees. There was no limitation of motion on extension and no pain on extension. There was no ankylosis of the knee joints. The range of motion of the joints was additionally limited in the right knee by pain, which was a major functional impact in the right knee, weakness with major functional impact, lack of endurance with major functional impact, but not by incoordination or fatigue. In the left knee, the motion of the joint was limited by pain, which was a major functional impact, by weakness, which was a major functional impact, and by lack of endurance, but not by incoordination or fatigue. The left knee had no major impact and was not limited by fatigue, weakness, lack of endurance, or incoordination. The Veteran reported one episode of buckling in the left knee, which the Board interprets as giving way in the normal plane of motion due to weakness. The examiner described the functional impairment as difficulty walking, standing, climbing stairs, and stooping. Symptoms of the right knee were described as pain, swelling, and weakness. The Veteran was limited in walking, climbing stairs, gardening, driving, and pushing a lawnmower. An April 2008 women's health note reveals full range of motion of both knees with some discomfort on extension of the right knee. A March 2009 general outpatient consultation reveals left knee range of motion intact and range of motion in the right knee measured from 0 degrees (180) to 90 degrees. The report of VA examination in November 2009 (see November 2010 addendum containing range of motion findings) reveals right knee flexion to 110 degrees, extension to 2 degrees, left knee flexion to 120 degrees, and left knee extension to 0 degrees. The Veteran estimated an additional 50 percent loss of function for walking, squatting, and climbing during flare ups. An April 2010 orthopedics resident note reveals range of motion of the right knee from 15 degrees to 100 degrees. Based on the April 2010 report that extension was limited to 15 degrees, the Board finds that a 20 percent rating for right knee arthritis was warranted as of April 28, 2010. The Board acknowledges that the effective date for the 20 percent rating need not correspond to the date of the examination report, but must be based on the earliest date as of which it is factually ascertainable that an increase in disability occurred. In this case, the Board cannot determine any date prior to the April 28, 2010 report that the criteria for a 20 percent rating were met. The Board emphasizes that the 20 percent rating under Diagnostic Code 5261 is not in addition to the 10 percent rating under Diagnostic Code 5003. The ratings under Diagnostic Code 5003 are for arthritis, which, prior to April 28, 2010 was not manifested by compensable limitation of flexion or extension. For the 10 percent rating to be applied under Diagnostic Code 5003, it was required that ratings for limitation of motion be noncompensable. As of April 28, 2010, the rating for extension became compensable, thus the 10 percent rating under Diagnostic Code 5003 was no longer warranted. The 20 percent rating under Diagnostic Code 5061 is applied in place of the 10 percent rating under Diagnostic Code 5003, not in addition to it. Since the expiration of the temporary total rating in November 1, 2011, there is no clinical evidence regarding range of motion. However, the right knee was evaluated during the 1-year period following the prosthetic replacement, and range of motion measurements were taken. One day after the surgery in July 2010, the right knee range of motion was from 20 degrees to 40 degrees. In August 2010, range of motion was from 15 degrees to 90 degrees. When evaluated in December 2010, the Veteran had full range of motion in the right knee; however, she was limited regarding prolonged standing, greater than 30 minutes. A December 2010 orthopedic clinic note reveals that the Veteran had been exercising and rehabilitating since her knee replacement and still had some limiting pain; however, the left knee was actually more painful than the right knee. Range of motion of each knee was from 0 to 110 degrees, which was painless. There was satisfactory stability in both flexion and extension. Strength was 4+ out of 5 in each knee. Thus, based on clinical findings establishing normal right knee extension and painless flexion to 110 degrees approximately 5 months after the prosthetic replacement, the Board finds no basis for a rating in excess of 30 percent for residuals of the prosthetic right knee replacement. Notably, the evidence demonstrates that there is not severe painful motion or weakness in the right knee, as would be required for a 60 percent rating under Diagnostic Code 5055. Prior to April 28, 2010, range of motion is noncompensable and the provisions of 5003 apply to produce a 10 percent rating. During this period, the functional impairment resulting from arthritis of the knees consisted primarily of pain associated with motion, resulting in limited motion and weakness, particularly in the right knee. The Veteran is competent to report her experience of such symptoms, and her diminished capacity due to such symptoms. Her descriptions are deemed credible. Regarding pain, while the provisions of 38 C.F.R. § 4.59 establish that the Veteran is entitled to at least the minimum compensable evaluation based on limited and painful motion, see also Burton v. Shinseki, 25 Vet. App. 1 (2011), such is already assigned for each knee. Evaluations in excess of the minimum compensable rating must be based on demonstrated functional impairment that meets the stated criteria. Although pain may cause a functional loss, pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id. at 38; 38 C.F.R. § 4.40. The Board acknowledges a finding of a VA clinician in August 2002 that there was moderate to "severe" osteoarthritis of the right knee. An August 2002 emergency room note also indicates "severe" bilateral arthritis. An April 2008 women's health note also reports "severe" arthritis of the right knee and moderate arthritis in the left knee, based on X-ray findings. Use of terminology such as "severe" and "moderate" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of any issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). Here, the rating schedule for arthritis does not include terminology such as severe, but directs that arthritis should be rated based on limitation of motion. The use of the term "severe" in describing the Veteran's arthritis is not probative evidence regarding range of motion. In other words, it does not suggest any particular degree of limitation. The range of motion readings are assigned greater probative weight than the use of the term "severe." The Board has acknowledged that the Veteran's pain is associated with a perception of weakness under certain circumstances. This weakness is considered functional impairment. However, the Board must balance the evidence of weakness and pain, which clearly limit motion and function, against the measured ranges of motion, as well as the clinical findings, which have mostly demonstrated normal or near-normal strength. In this case, the weakness demonstrated does not suggest any higher ratings than are already applied. The Board acknowledges the Veteran's central concern that she has painful knee disabilities which limit her ability to engage in activities of daily life and employment; however, it is important for the Veteran to understand that, without some functional impairment associated with the knees, there would be no basis for the current ratings. It is also important to note that the left knee range of motion testing conducted in this case not only does not meet the criteria for a rating higher than 10 percent, it does not actually meet the range of motion requirements of the 10 percent ratings currently assigned. Moreover, with the exception of the period from April 28, 2010 to July 14, 2010 during which a 20 percent rating is assigned for the right knee, the range of motion testing for the right knee does not meet the requirements for a 10 percent rating. The current 10 percent ratings for arthritis under Diagnostic Code 5003 are assigned based on the presence of pain and associated limitation. Without consideration of the problems of pain and weakness the Veteran has described, the current evaluations could not be justified, let alone any higher evaluation. In this regard, it is important to note that Regarding Diagnostic Code 5257, for the right knee, the assignment of a 30 percent rating for prosthetic knee replacement precludes any further rating under Diagnostic Code 5257. The Board notes that Diagnostic Code 5055 directs to rate on residual limitation of motion under Diagnostic Codes 5256, 5260, and 5261. Prior to July 14, 2010, the 20 percent rating for the right knee under Diagnostic Code 5257 is assigned based on moderate recurrent subluxation or lateral instability. In order to warrant a higher 30 percent rating, the evidence would have to demonstrate severe recurrent subluxation or lateral instability. Moreover, in order to warrant a separate rating under Diagnostic Code 5257 for the left knee, the evidence would have to demonstrate at least slight recurrent subluxation or lateral instability. The December 2002 VA examiner found no ligamentous problems with either knee. An August 2002 orthopedic clinic note reveals negative Lachman's, anterior drawer, and posterior drawer for the right knee. The right knee was stable to varus and valgus stress. A September 2002 treatment report notes negative Lachman's and drawer for the right knee with a positive McMurrays and medial/patella grind. The report of VA examination in July 2003 reveals that the general appearance of both knee joints was within normal limits. The Veteran required a neoprene brace for the right knee because of pain. A March 2009 general outpatient consultation reveals a finding of no laxity with respect to either knee, but with positive anterior/posterior drawer testing in the right knee. The November 2009 VA examiner found no instability, dislocation, or subluxation of either knee. Based on this evidence, the Board finds that there is no basis to assign a separate compensable rating under Diagnostic Code 5257 for the left knee, and no basis for an increased rating for the right knee prior to July 14, 2010. Severe lateral instability or recurrent subluxation of the right knee is not demonstrated. There would appear to be no appreciable lateral instability or recurrent subluxation of the left knee. The Board acknowledges that the Veteran has reported a perception of instability. She reported in a March 2009 general outpatient consultation that she feels the knees are unstable at times and she has fallen a few times. The Board observes that the term instability can have several meanings, including instability in the normal plane of motion of the joint (weakness, buckling, giving way). Lateral instability is a specific type of instability that is demonstrated by clinical testing, such as Lachman, anterior drawer, and varus, and valgus stress. As set out above, the clinical evidence consistently shows that there has been no lateral instability of the left knee at any time pertinent to the appeal. While giving way has been described by the Veteran as instability, the criteria are specific in referring to "lateral" instability, and not instability in the normal plane of motion, which is considered as weakened or limited motion. The Board finds the clinical test results to be more probative as to the presence of lateral instability than the Veteran's assertions, which are imprecise as to the nature of the perceived instability. Indeed, she has not specifically asserted that she experiences lateral instability or recurrent subluxation. As there is clinical support for weakness, but no clinical support for lateral instability of the left knee, the Board has considered the Veteran's reports of instability as equivalent to weakness or giving way. Diagnostic Code 5258 rates on the basis of dislocation of the semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. A 20 percent rating is the only rating available. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of the semilunar cartilage. There are no reports of dislocation or removal of semilunar cartilage for the left knee. The November 2009 examiner estimated locking episodes for the left knee at less than once per year. The Board finds that this would not satisfy the requirement of "frequent" episodes of locking, pain, and effusion into the joint. Regarding the right knee, the Veteran has undergone multiple arthroscopic procedures during and after which 100 percent ratings were assigned. Moreover, the assigned rating under Diagnostic Code 5257 is based on the meniscal and ligament injuries that would form the basis of a rating under Diagnostic Code 5258. Thus, separate ratings under Diagnostic Code 5257 and 5258 would not be appropriate, but would constitute pyramiding. Moreover, as a 20 percent or higher rating is already assigned under 5257, a rating under Diagnostic Code 5258 would not prove an advantage during any portion of the appeal period. Diagnostic Code 5262 rates on the basis of malunion or nonunion of the fibula and tibia, conditions which are neither shown nor alleged in this case. Diagnostic Code 5263 rates on the basis of genu recurvatum, a condition which is neither shown nor alleged. Accordingly, these codes are not appropriate. The Board has also considered whether a separate rating might be warranted for reported leg length discrepancy, which may or may not be related to a service-connected disability. The December 2002 examiner described a 1-inch discrepancy. The July 2003 examiner described only a .5 centimeter discrepancy. The minimal compensable rating under Diagnostic Code 5275 requires a 11/4-inch or 3.2 centimeter discrepancy. Accordingly, a compensable rating is not warranted. There are no reported scars of the left knee. The surgical scar for the right knee was described by the July 2003 examiner as 4 centimeters, non disfiguring, with no evidence of keloid formation, ulceration, tenderness, underlying tissue loss, or limitation. An August 2002 clinical note reveals well healed surgical scars. Accordingly, there is no basis for the assignment of a compensable rating on the basis of scar residuals. As higher ratings for right knee instability and arthritis, or for left knee arthritis, are not warranted, and as no other diagnostic codes are appropriate, the Board finds that the weight of the evidence is against a rating in excess of 10 percent for arthritis of the left knee, is against a rating in excess of 10 percent for arthritis of the right knee prior to April 28, 2010, is against a rating in excess of 20 percent for arthritis of the right knee from April 28, 2010 to July 14, 2010, is against a rating in excess of 20 percent for right knee instability prior to July 14, 2010, is against a rating in excess of 30 percent for prosthetic right knee replacement since September 1, 2011, and is against any separate compensable ratings for either knee disability. To the extent any higher level of compensation is sought, the preponderance of the evidence is against the claims, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2013), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the schedular rating criteria contemplate the Veteran's service-connected knee disabilities. The criteria specifically provide for ratings based on the presence of lateral instability, recurrent subluxation, and prosthetic knee replacement, as well as limited flexion and extension, including due to pain, weakness, fatigue, and incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59. Such factors are explicitly part of the schedular rating criteria and have been considered in detail. The functional impairment described by the Veteran relates directly to these factors. Accordingly, the Board finds that the schedular criteria fully contemplate the Veteran's disability picture. Because the schedular rating criteria are adequate to rate the disabilities, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Service Connection Left Ankle The Veteran is seeking service connection for a left ankle disability on the basis that it was incurred or aggravated secondary to a service-connected knee disability. There is no dispute as to two of the elements necessary for service connection. There is a current left ankle disability diagnosed as arthritis. Service connection is also in effect for disabilities of the bilateral knees. The RO obtained a VA examination in November 2009. The examiner opined that the Veteran's left ankle arthritis was less likely as not caused by her knee disabilities. The basis was that there was radiographic evidence of previous fracture and deformity of the left ankle. The requested opinion regarding aggravation was not initially provided. A November 2010 addendum was obtained by the RO with the requested opinion. The examiner opined that, although the left ankle arthritis was not caused by the service-connected knee disabilities, it was more likely than not aggravated by the bilateral knee disability. The mechanism of aggravation was the Veteran's abnormal gait. The RO did not mention this opinion in the subsequent supplemental statement of the case. The law provides that any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b) (2013). However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b) (2013). In essence, the Board cannot grant service connection for aggravation of the left ankle disability regardless of a positive medical opinion unless and until the extent of aggravation is determined by medical evidence. After a review of all of the evidence, the Board finds that the evidence demonstrating a causal connection between the current left ankle disability and the Veteran's service-connected knee disabilities is in relative equipoise with the evidence against causation. Accordingly, a decision regarding aggravation is not required. In essence, the Board finds that the November 2009 opinion and November 2010 addendum opinion are based substantially on an inaccurate factual premise. First, the opinion that there is no causal connection because the left ankle disability is shown by X-ray evidence to have been caused by a prior trauma begs the questions what was the prior trauma, and what caused it. Here, the opinion appears to ignore, or at least does not discuss, the Veteran's report to a May 1997 VA examiner (5 years before the current claim) that her right knee would lock on occasion, causing her to fall. She reported a recent fall from a curb during which she twisted her left ankle and injured her left knee. At the time of the examination, there were no reported left ankle symptoms and X-rays of the left ankle were not taken. No diagnosis for the left ankle was provided. The examiner found that the left knee disability was related to service-connected right knee disability. Notably, the RO granted service connection for the left knee disability based on the May 1997 examiner's opinion. The Veteran is competent to report an injury to her left ankle, as well as the cause of the injury. The May 1997 report is entirely consistent with a prior trauma to the left ankle, caused by the right knee. However, the November 2009 opinion does not address or acknowledge this report. The Board finds that the May 1997 account is particularly persuasive because it was not given in the course of a claim for benefits for the ankle disability. The Veteran would not file such a claim for many years, following an apparent recurrence of ankle symptoms in 2002. Thus, she had no apparent motive for reporting the injury, other than to provide appropriate details to the examiner. The Board acknowledges that the Veteran is not necessarily competent to relate the August 2002 recurrence of symptoms to the original injury, which is somewhat remote in time; however, the November 2009 and November 2010 opinions essentially provide this evidence. The November 2009 opinion was that the current ankle disability was related to the prior trauma and not to an altered gait. The missing piece of the discussion was that, as found here by the Board, the prior trauma was related to the right knee disability. To the extent of any remaining doubt, such doubt is resolved in favor of the claim. Service connection for a left ankle disability is warranted. The Veteran is seeking service connection for a right elbow disability, which she relates to a fall in 2002, claimed due to her knee disabilities. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that there is no current right elbow disability. The Veteran is competent to describe her symptoms of a right elbow disability, as well as their point of onset. The Board does not dispute the Veteran's account of the fall. The Veteran reported in the VA Form 9 that the elbow was sore and weak and "pop out of socket." However, the Veteran was evaluated after the fall and X-rays of the elbow were taken. They show no evidence of fracture, dislocation, or osteoarthritis. The soft tissues were unremarkable. While the Veteran is competent to report her symptoms, the Board finds the X-ray evidence to be more reliable in terms of identifying a disorder of the elbow. It does not appear that the Veteran has subsequently sought treatment for her elbow complaints, nor has she reported symptoms to VA since the 2005 VA Form 9. Also significant as to the presence of a current disability is the fact that the Veteran has been inconsistent in identifying which elbow is currently symptomatic. In the claim form, she identified the right elbow. However, in the notice of disagreement, she initially wrote the right elbow, then crossed out "Right el" and substituted "Left elbow." In the VA Form 9, she acknowledged the confusion and noted that the right elbow was the injured elbow. The Board finds that, in the context of identifying a disability for which current symptoms are asserted, it is beyond credibility for there to be any confusion as to which elbow is involved. Either there are current symptoms or there are not. If there are current symptoms, the location of those symptoms should be immediately apparent. The Veteran's confusion, albeit temporary, is consistent with the absence of current symptoms. The Board finds that the Veteran's assertions as to current right (or left) elbow symptoms are not accurate. While the presence of a disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative, McClain v. Nicholson, 21 Vet. App. 319 (2007), Congress has specifically limited entitlement to service-connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. § 1110. Hence, where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Based on the lack of any disorder of the right elbow, despite medical evaluation of the joint, the Board finds that service connection for a right elbow disability is not warranted. Service Connection Posttraumatic Stress Disorder The Veteran asserts that she incurred PTSD due to a personal assault during her service. For reasons that will next be discussed, the Board finds that the Veteran's accounts of the personal assault have been materially inconsistent with one another and these inconsistencies undermine the credibility of her assertions. While the record contains diagnoses of PTSD as well as other psychiatric disorders, the Board finds that the asserted stressor involving personal assault is not verified and cannot be verified because it is factually inaccurate. The Veteran served from July 1981 to August 1983. The first reference to psychiatric symptoms in the record comes in the February 1999 claim on which the Veteran noted that she would like to be considered for service connection for PTSD. She did not describe any stressors at that time. A July 2004 psychiatry/mental health note reveals that the Veteran had been under psychiatric care since 1998 and had been using drugs since 1989. In September 1999, the Veteran was admitted to an in-patient VA drug dependence treatment program. During this admission, a psychological assessment was conducted. Notably, in this initial assessment, the Veteran's account to the examiner was that she had no history of sexual abuse, providing highly probative factual evidence against her own claim at this time. The Board finds this statement to be highly credible as it was done prior to any claim during a time when the Veteran was attempting to end her drug dependency. If a sexual assault of the nature the Veteran has cited did occur in service, the Board finds it highly likely that she would have cited it during this assessment as medical providers looking for the source of her drug addiction would be seeking to address such problems actively in combating the Veteran's clear drug abuse problem. The Veteran recounted her service details as: often in trouble for showing up late. She also claimed her heaviest marijuana and drinking were in the military. She did not mention any type of assault in the service, importantly while citing her military service. A November 2000 discharge summary includes diagnoses of substance induced psychotic disorder and mixed personality disorder. A December 2000 discharge summary includes diagnoses of alcohol mood disorder, schizoaffective disorder, marijuana abuse and mixed personality disorder. VA treatment records reveal multiple admissions to VA psychiatric treatment units starting in August 2002 for diagnoses of schizoaffective disorder, cocaine dependence, drug depressive syndrome, alcohol induced psychosis, and various personality disorders. An August 2002 psychiatric note reveals that the Veteran sought readmission to a substance abuse treatment program and when she was referred to psychiatric emergency services for evaluation, she took a razor blade from her belongings and made a small scratch on her left wrist. At emergency services, the Veteran verbalized having been raped in the service. In a September 6, 2002 psychology note, the Veteran reported that she had been raped at the age of 4. In a September 17, 2002 psychology note, the Veteran repeated her assertion that she had been sexually assaulted at the age of 4, and added that she had also been assaulted in the military. In an October 2002 psychology progress note, the Veteran again recounted having been raped in the military and that she would consider a referral to the women's clinic. In a December 2002 psychiatric evaluation, the Veteran denied any sexual abuse as a child, but reported 2 incidents of sexual abuse by her superiors in the service. A December 2002 VA examination report reveals the Veteran's account that she became sexually active at 14 and became more active in her 20s. She did not report any incidents of sexual assault in this instance. In an October 2003 stressor statement, the Veteran reported that, at Fort Benning, she was assigned to a maintenance battalion and was on her way to her room. As she walked down the hall to her room, "these guys" pulled her in to another room and held her down and took turns sexually assaulting her. After this, she requested a transfer. She reported that, then, the platoon sergeant started to "feel on me." She reported that he gave her a hard time when she did not cooperate. The Veteran continued that, after her transfer to Germany, an SP-4 whose name she does not remember pinned her next to a bench and started grabbing her and unfastening her clothes. In a March 2004 VA psychiatric evaluation, the Veteran reported that she had been sexually harassed and fondled by one of the sergeants while stationed in Georgia. Later on, she was raped by two men who were in the same co-ed building with her. She was invited to their room to show some educational material. Then, the room was shut off and she was forced into sexual relations with the two men. In a hand-written account received in November 2007, the Veteran reported that she attended a barbeque near a lake with "weed" and alcohol and other substances. According to the Veteran, a platoon sergeant came on to her. Two days later, she was raped by two guys from the picnic. She also reported that, after transfer to Germany, an individual pinned her up against a bench and assaulted her. The Board notes that, while the Veteran has an extensive history of drug and alcohol abuse, the Board does not consider this to be evidence weighing against her claim. The Board acknowledges that drug and alcohol abuse in some instances can be a consequence of personal trauma and psychiatric/mental impairment. The Board emphasizes that the Veteran's account is in no way discredited by her history of drug and alcohol abuse. Rather, it is the numerous inconsistencies in the various tellings of her account to which the Board attaches greatest significance. It is notable that the Veteran does not remember the name of any individual who allegedly assaulted her in the service, despite remembering such details as the rank and duty assignments of these individuals, but more important is the inconsistency of detail from one telling to the next that serves to undermine the credibility of the Veteran's assertions. While the Board would not expect such attacks to always be reported in service (and clearly many are not - the problem of sexual assault in service cannot be underestimated) and would also not expect the Veteran to recall every detail of the events, not only is the order of events reversed in the first two accounts, details of the events are irreconcilably different in each account. In the 2003 account, the platoon sergeant groped her after the alleged sexual assault by 2 individuals at her barracks. In the subsequent accounts, the order of events was reversed. It would seem that this would not be a small detail. Indeed, in the 2007 account, she was quite specific that the assault by the sergeant came 2 days after the sexual assault by 2 individuals. The alleged assault by two individuals in the 2003 telling was presented as somewhat random, as she was alleged to have been pulled into a room as she walked down the hall. In the 2004 telling, she was allegedly invited to view some sort of educational material. Thus, in one account, she was forcibly taken into the room, and in the other, she entered voluntarily, but under false pretenses. Either one account is false, or they are both false; however, they cannot both be true. Similarly, either her account in 1999 that she had no history of sexual abuse is false, or her later account of in-service sexual abuse told in the context of her claim for PTSD disability benefits is false; however, they cannot both be true. While not directly pertinent to the claim, the Veteran has also alternatively reported that she was raped as a child of 4, that she was never sexually assaulted as a child, and that she first became sexually active at 14. There is no way to reconcile these accounts without at least one of them being false. The Board certainly acknowledges that it would not be expected for every detail of events such as described by the Veteran to be recounted in the initial telling or in subsequent retellings. An individual might reasonably tailor the information she recounts to the needs of the individual who is requesting the information. A stressor statement recounted to VA for claims purposes might contain different details than an account given to a healthcare provider. However, when material facts change from one telling to the next, this undermines the credibility of the entire account. Such is the case here: The Board finds that the Veteran's assertions as to being personally assaulted in the service are materially inconsistent with one another and are lacking in credibility. The Board acknowledges that the record contains a diagnosis of PTSD by a VA examiner in March 2004. However, this diagnosis is explicitly based on the reported stressors of military sexual assault, which the Board has found to be inaccurate. In Patton v. West, 12 Vet. App. 272 (1999), the United States Court of Appeals for Veterans Claims (Veterans Court) held that special consideration must be given to claims such as this one for service connection for PTSD based on personal assault. In particular, the Veterans Court held that the provisions in VA's Adjudication Manual which addressed PTSD claims based on personal assault are substantive rules which are the equivalent of VA regulations and must be considered. See also YR v. West, 11 Vet. App. 393, 398-99 (1998). Moreover, evidence other than the Veteran's service records can corroborate the occurrence of a claimed in service stressor based on personal assault. See 38 C.F.R. § 3.304(f)(5). Examples of such evidence include evidence of behavior changes following the claimed assault. Examples of behavior changes that may constitute credible evidence of a stressor include deterioration in work performance and episodes of depression, panic attacks, or anxiety without an identifiable cause, or unexplained economic or social behavioral changes. 38 C.F.R. § 3.304(f)(5) also provides that VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. In Menegassi v. Shinseki, 628 F.3d 1379 (Fed. Cir. 2011), the Federal Circuit held that under 38 C.F.R. § 3.304(f)(5), medical opinion evidence may be submitted for use in determining whether there was occurrence of a claimed stressor, and such opinion evidence should be weighed along with the other evidence of record in making this determination. Id. at 1382 & n. 1. Service records show that the Veteran began her tour of duty at Fort Benning, Georgia in July 1981. She was ordered to report to her new duty station in Germany in March 1982, and she was officially transferred to Germany in August 1982. A record of informal counseling in October 1982 indicates that the Veteran had been late for 2 formations and had not been at her appointed place of duty a number of times. The following month, it was noted that she had been steadily improving in her skills, her outlook was generally good, and she worked well with others, but needed to work on responsibility and placement of priorities. In December 1982, it was noted that her attitude, duty performance, and personal appearance were among the best in the company. She was recommended for promotion. In January 1983, the Veteran was counseled for disregarding instructions by an officer and lack of motivation. In February 1983, she was found to show a negative attitude towards assigned tasks and regular duty requirements. In April 1983, the Veteran was instructed to move out of her assigned room, but refused, stating she had other things to do. In June 1983, the Veteran was found to have violated Article 90 of the universal code of military justice by disobeying orders and by falsifying a sick slip giving herself 48 hours quarters. Thus, the record demonstrates a mixed history of performance issues during service. However, the Veteran reported that her first sexual assaults took place at Fort Benning. She left Fort Benning in August 1982. With the exception of being late for formation, it does not appear that serious performance difficulties began until early 1983. In fact, she was commended for her performance and attitude in December 1982. Based on her service records, there does not appear to be any direct temporal correlation between the onset of disciplinary problems and the first alleged assault. Moreover, the Board has found that the Veteran's account of multiple sexual assaults in service is materially false based on a pattern of inconsistencies in her accounts and not based on any lack of corroborating evidence, such as might be demonstrated by performance issues in service. Simply put, the Veteran has shown herself to be an unreliable historian. A remand to obtain an opinion from a clinician regarding the acknowledged performance problems during service and whether these problems corroborate her inconsistent accounts would necessarily produce speculative and unreliable evidence, making the doctor the fact finder. Turning to the Veteran's alternative assertion, that she incurred a psychiatric disability other than PTSD directly due to service. Service treatment records reveal no treatment for psychiatric issues during service. The Veteran was examined at service separation and was found to be psychiatrically normal. A mental status evaluation conducted in July 1983 reveals that the Veteran demonstrated normal behavior, mood, and thought content, was fully alert and oriented, and demonstrated a clear thinking process and good memory. In the examiner's opinion there was no significant mental illness, the Veteran was mentally responsible, was able to adhere to the right, and was able to distinguish right from wrong. The first reference to psychiatric symptoms in the record comes in the February 1999 claim on which the Veteran noted that she would like to be considered for service connection for PTSD. However, at that time, the Veteran provided no other details. Post-service records reflect an ongoing history of in-patient and outpatient treatment for alcohol, cocaine, and other substance abuse. She apparently attended an in-patient substance rehabilitation program in 1991, the records of which have not been identified. The first reference to treatment for a psychiatric disability comes from a September 1999 psychology progress note in which it was noted that the Veteran had a history of cocaine use and had been in drug rehabilitation facilities in 1991 and in July 1999. It was also noted that the Veteran was being treated for schizoaffective disorder. This is more than a decade after service separation. To the extent that schizoaffective disorder constitutes a psychosis, this is well more than the 1-year presumptive period. In June 2003 correspondence, the Veteran asserted that she was discharged early from the Army with multiple problems with following directions, going to work, acting appropriate with others and mood swings. Thus, in addition to her assertions regarding PTSD and in-service incurrence of a psychiatric disability, the Veteran also asserts that she had symptoms of a psychiatric disability in service and continuously after service. Significant in terms of the onset of psychiatric symptomatology, the current claim was not the first claim for disability compensation filed by the Veteran since service separation. The Veteran filed a claim in June 1992; however, at that time, she noted only a right knee disability as related to service. In July 1993, the Veteran filed a claim seeking service connection for a left knee disorder. The Veteran did not mention any psychiatric or mental disorder in either claim. While inaction for many years regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it is reasonable to expect that the Veteran is presenting all issues for which she is experiencing symptoms that she believes are related to service. In other words, the Veteran demonstrated as early as 1992 that she understood the procedure for filing a claim for VA disability compensation, and she followed that procedure in several other instances where she believed herself entitled to those benefits. In such circumstances, it is reasonable to expect a complete reporting of symptoms. The failure to report psychiatric symptoms at those times is reasonably interpreted as either the lack of such symptoms, or the Veteran's belief that they were not related to service. Either interpretation undermines her current assertion that a current psychiatric disability is related to service, either directly, or through continuous symptoms. There is no medical opinion that purports to relate an acquired psychiatric disability other than PTSD to service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), establishing the etiology of a psychiatric disability falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In sum, the Veteran's accounts of PTSD stressors in service are materially inconsistent and are deemed inaccurate based on these discrepancies. The stressors are not verified and no further development to verify the stressors is necessary. There is no diagnosis of PTSD based on a verified stressor. The Veteran was not treated in service for psychiatric symptoms and was psychiatrically normal at service separation. A psychosis did not become manifest within 1 year of service separation and symptoms of a psychosis were not continuous after service. A current psychiatric disability other than PTSD is not medically related to service. Accordingly, service connection for an acquired psychiatric disability, to include PTSD, is not warranted. In reaching this conclusion, 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, 1 Vet. App. at 53-56. Duties to Notify and Assist The Veteran does not contend that there was any deficiency in the notice provided her regarding any of the claims decided herein. The Board remanded this appeal in September 2009 in part to address VCAA notice issues. The Board finds that VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, and the Veteran's written assertions. The Veteran has not identified any additional outstanding medical records. In addition, the Veteran was afforded VA examinations to address the manifestations and severity of the service-connected knee disabilities. These examinations are adequate because each was performed by a medical professional based on a review of claims file or solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The reports include findings that address the rating criteria. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). A medical opinion was not requested regarding the claimed right elbow disability. Moreover, neither an etiology opinion nor an opinion as to the validity of a claimed PTSD stressor has been obtained. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Veterans Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard of subsection (B), as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. As the Board has found that there is no current right elbow disability, the Board finds that a medical etiology opinion is not necessary. Moreover, as the Board has found the Veteran's account of her PTSD stressor to be materially false, and that there was no psychiatric disability or symptoms of a psychiatric disability in service, the Board finds that an opinion regarding the validity of the claimed PTSD stressor and a psychiatric nexus opinion are not necessary. In essence, the only evidence that the Veteran's claimed psychiatric disability is related to her military service consists of her own conclusory generalized lay statements, which are unsupported by even speculative medical evidence. Accordingly, the Board finds that referral for a VA medical examination is not warranted. ORDER Prior to April 28, 2010, a separate disability rating of 10 percent, but not higher, for right knee arthritis is granted. From April 28, 2010 to July 14, 2010, a 20 percent rating for right knee arthritis is granted. Prior to July 14, 2010, a disability rating for right knee instability in excess of 20 percent is denied. Since September 1, 2011, a disability rating for right knee prosthesis in excess of 30 percent is denied. A disability rating for left knee arthritis in excess of 10 percent is denied. Service connection for a left ankle disability is granted. Service connection for a right elbow disability is denied. Service connection for PTSD is denied. Service connection for an acquired psychiatric disability other than PTSD is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs