Citation Nr: 1542823 Decision Date: 10/05/15 Archive Date: 10/13/15 DOCKET NO. 09-34 545 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a right knee disability, to include on a secondary basis. 2. Entitlement to service connection for a hip disability, to include on a secondary basis. 3. Entitlement to service connection for a low back disability, to include on a secondary basis. 4. Entitlement to service connection for headaches, to include on a secondary basis. 5. Entitlement to an increased rating for internal derangement of the left knee with arthritis, currently evaluated as 20 percent disabling. WITNESSES AT HEARING ON APPEAL Appellant and L.H. ATTORNEY FOR THE BOARD Mary E. Rude, Associate Counsel INTRODUCTION The appellant served on active duty from August 1964 to July 1968. These matters are before the Board of Veterans' Appeals (Board) on appeal from September 2007 and August 2009 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In March 2011, the Veteran testified at a videoconference hearing before the undersigned; a transcript of that hearing is of record. In September 2011, these issues were remanded for additional development. They have now been returned to the Board for adjudication. The Board notes that the September 2011 remand included the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). In January 2012, the Veteran submitted a Form 9 substantive appeal for entitlement to a TDIU and requested a Board hearing on this issue at a local VA office. A hearing has been scheduled for December 2015. This issue is therefore not ready for adjudication by the Board at this time, and will be addressed in a separate decision following the scheduled hearing. The claims file is now entirely in VA's secure electronic processing systems, Virtual VA and Veterans Benefits Management System (VBMS). The issue of entitlement to service connection for headaches is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A right knee disability is not shown to be the result of any incident of the Veteran's active military service, it did not manifest to a compensable degree within one year of separation from service, and it is not causally related to or made worse by service-connected internal derangement of the left knee with arthritis. 2. A bilateral hip disability is not shown to be the result of any incident of the Veteran's active military service, it did not manifest to a compensable degree within one year of separation from service, and it is not causally related to or made worse by service-connected internal derangement of the left knee with arthritis. 3. A low back disability is not shown to be the result of any incident of the Veteran's active military service, it did not manifest to a compensable degree within one year of separation from service, and it is not causally related to or made worse by service-connected internal derangement of the left knee with arthritis. 4. The Veteran's internal derangement of the left knee with arthritis has manifested by episodes of swelling and pain. It has not manifested by flexion limited to 60 degrees or extension limited to 5 degrees, including due to pain or following repetitive motion. There is no evidence of right knee ankylosis, recurrent subluxation, lateral instability, a cartilage disorder, or genu recurvatum. CONCLUSIONS OF LAW 1. A right knee disability was not incurred or aggravated during service, it may not be presumed to have been so incurred, and it is not secondary to service-connected internal derangement of the left knee with arthritis. 38 U.S.C.A. §§ 1110, 1112, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2014). 2. A bilateral hip disability was not incurred or aggravated during service, it may not be presumed to have been so incurred, and it is not secondary to service-connected internal derangement of the left knee with arthritis. 38 U.S.C.A. §§ 1110, 1112, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310. 3. A low back disability was not incurred or aggravated during service, it may not be presumed to have been so incurred, and it is not secondary to service-connected internal derangement of the left knee with arthritis. 38 U.S.C.A. §§ 1110, 1112, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310. 4. The criteria for a rating in excess of 20 percent for internal derangement of the left knee with arthritis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5256-5261 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014)) defines VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA are codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2014). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits. Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In March 2007, June 2007, and July 2008 letters, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claims, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. He was also advised of how disability evaluations and effective dates are assigned, the type of evidence that impacts those determinations, and the elements required for establishing service connection on a secondary basis. The claims were last adjudicated in the November 2014 Supplemental Statement of the Case. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including service treatment records, VA treatment records, the Veteran's personal statements, and his personal hearing testimony. In September 2011, the issues were remanded, in part, to obtain a VA examinations and opinions. VA examinations were held in February 2012 and October 2013, and an addendum medical opinion was provided in May 2013. The Board finds that the VA examinations and opinions are adequate to decide the claims on appeal because, as shown below, they were based upon consideration of the Veteran's medical history, including his lay assertions and his current complaints, and because they sufficiently inform the Board of the examiners' judgment on those medical questions and the examiners' essential rationale for the opinions. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-106 (2012). The examination reports were associated with the claims file and reviewed prior to the issuance of the November 2014 Supplemental Statement of the Case. The Board therefore finds that there has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008). Lastly, during the March 2011 Board hearing, the undersigned explained the issues on appeal and suggested the submission of evidence that may have been overlooked. These actions provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103(c)(2) and consistent with the duty to assist. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). II. Relevant Regulations and Laws Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'-the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In the case of aggravation by a service-connected disability, a veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Id. Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C.A. § 1101(3) or 38 C.F.R. § 3.309(a) (2014). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As the Veteran has been diagnosed with degenerative joint disease/arthritis, a chronic disease, the Board will consider whether 38 C.F.R. § 3.303(b) is for application. In addition, for veterans with 90 days or more of active service during a war period or after December 31, 1946, chronic diseases such as arthritis are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. The credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); Colvin v. Derwinski, 1 Vet. App. 171 (1991). Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1999). Nevertheless, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods within the period on appeal. Where there is a question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. The Veteran's internal derangement of the left knee with arthritis is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5258, for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § .71a, Diagnostic Code 5258. Disabilities of the knee can also be rated based on limitation of motion. Diagnostic Codes 5256, 5261, and 5262 pertain to functional limitation of the knee. VA regulations, set forth at 38 C.F.R. §§ 4.40, 4.45, and 4.59, provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. The United States Court of Appeals for Veterans Claims has held that a higher rating can be based on "greater limitation of motion due to pain on use." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Any such functional loss must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." 38 C.F.R. § 4.40. For VA purposes, a normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Limitation of extension of the leg is evaluated as follows: extension limited to 20 degrees (30 percent); extension limited to 15 degrees (20 percent); extension limited to 10 degrees (10 percent); and extension limited to 5 degrees (0 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5261. Limitation of flexion of the leg is evaluated as follows: flexion limited to 15 degrees (30 percent); flexion limited to 30 degrees (20 percent); flexion limited to 45 degrees (10 percent); and flexion limited to 60 degrees (0 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5260. Separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same joint, if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04; 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14. VA General Counsel has also held that a claimant who has both arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98; 63 Fed. Reg. 56704 (1998). Slight recurrent subluxation or lateral instability of the knee warrants a 10 percent disability rating, and a 20 percent disability rating is in order for evidence of moderate recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. VA's Schedule of Disability Ratings will apply unless there are exceptional or unusual factors that would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). III. Right Knee Disability The Veteran contends that he has a right knee disability which is secondary to his service-connected internal derangement of the left knee with arthritis. The Veteran stated at the March 2011 Board hearing that he uses his right knee "all the time" because he is unable to use his left knee. Board Hearing Transcript (Tr.) 7. The Veteran's service treatment records are silent for any complaints or treatment relating to the right knee, and his VA treatment records show no treatment or diagnoses for the right knee. The Veteran's bi-yearly check-up examinations from November 2008 to December 2011 show full range of motion in all joints, other than the left knee, with no swelling, tenderness, or warmth. The Veteran underwent a VA examination in February 2012 by an examiner who reviewed the claims file and performed an in-person examination of the Veteran. The Veteran reported that his right knee sometimes swelled due to over-use, but denied ever having to care for his right knee, and he denied having pain in the right knee. The examiner noted that the Veteran had never been previously diagnosed with a right knee condition. X-rays showed early degenerative changes of the right knee, with joint spaces maintained. The examiner diagnosed the Veteran with early degenerative joint disease. The examiner opined that the Veteran's disorder was less likely than not related to an in-service injury, event, or illness, explaining that the Veteran's medical records showed no post-service care for a right knee disability or condition. He stated that there were no secondary conditions found associated with the left knee, and that the degenerative changes to the right knee found on X-ray were not related to the left knee condition. He wrote that these findings were etiologically associated with aging and not the left knee, and that there was no etiological association between the X-ray findings and military service or the left knee. He summarized his findings stating that there was no currently diagnosed right knee disability that was etiologically related to service or was caused or aggravated by service-connected internal derangement of the left knee with arthritis. After reviewing the evidence described above, the Board finds that the preponderance of the evidence is against a finding that the Veteran has a right knee disability that is related to service or was caused or aggravated by his service-connected internal derangement of the left knee with arthritis. The Board finds that the February 2012 examination report provides an adequate medical opinion which states that the Veteran's right knee early degenerative joint disease was not caused or aggravated by his service-connected left knee disorder. The examination was performed by a competent examiner based on a personal examination of the Veteran, as well as on review of recent X-ray findings and the medical record. He afforded full consideration of the Veteran's documented medical history and his assertions, including noting that the Veteran reported occasional swelling in his right knee. The examiner provided adequate rationale for his findings, and responded to the necessary questions. The Board finds that this competent and probative medical opinion is to be afforded great probative weight. See, e.g., Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusions reached.). The only evidence indicating that the appellant has a current right knee disability which is secondary to his service-connected left knee disability lies within the lay statements of the Veteran himself. To the extent that the appellant's assertions are advanced to establish a medical nexus, such evidence is not found to outweigh the competent and probative opinion of the VA examiner. The Veteran, as a layperson, is competent to report on matters observed or within his personal knowledge such as symptoms of pain. Questions of medical diagnosis and causation of disabilities not capable of lay observation or sensory perception remain within the province of medical professionals. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (2007); Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As a layperson without the appropriate medical training or expertise, the Veteran is not competent to render a probative opinion on such a medical matter. Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Hence, lay assertions as regarding either the nature or etiology of the Veteran's complaints of specific symptoms associated with a complex process such as degenerative joint disease have little probative value. While the Veteran is competent to say that he has occasional pain and swelling in his right knee, he is not competent to diagnose his right knee disability or to determine the cause of these symptoms. Thus, the Veteran's opinion that his right knee disability was caused or aggravated by his left knee disability is not a competent medical opinion. In any event, even assuming the Veteran's competence to opine on this question, the Board finds the specific opinions of a trained health care professional after examination to be of greater probative weight than the Veteran's general lay assertions. While lay witnesses are competent to testify as to their observations, this testimony must be weighed against the other evidence of record. See Jandreau, 492 F.3d at 1376-77; Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). As such, the medical findings and opinion of the May 2013 VA examiner warrant greater probative weight than the Veteran's lay contentions regarding the etiology of his osteoarthritis. The Board notes that while the Veteran has only alleged that his right knee disability is secondary to his service-connected left knee disability and not that it was directly incurred in service, there is nonetheless also no evidence indicating that a right knee disability was incurred in or related to service. The February 2012 VA examiner opined that the Veteran's right knee disability was not incurred in or related to service, and there are no contrary medical opinions to this assertion. There is no evidence of record indicating that the Veteran had any injury to the right knee in service, and no evidence linking his current right knee early degenerative joint disease to any event or injury in service. While degenerative joint disease is a chronic disease, there is no evidence of this disorder in service or a continuity of symptomatology since service. See 38 C.F.R. § 3.303(b). Furthermore, while service connection for arthritis may be granted if manifested to a compensable degree within one year of separation from active duty, the is no evidence in this case that the Veteran had right knee arthritis within this timeframe, nor has he asserted that he had. Thus, service connection under a direct or presumptive basis is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). In sum, the preponderance of the evidence fails to show that the Veteran's right knee disability was incurred in or otherwise related to any event or illness in active duty service, that it manifested within one year of separation from service, or that it was caused or aggravated by his service-connected internal derangement of the left knee with arthritis. The Board therefore finds that the claim of entitlement to service connection for a right knee disability is denied. In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the appellant's claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); See, e.g., Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). IV. Hip Disability The Veteran contends that he has a bilateral hip disability that was caused by his service-connected internal derangement of the left knee with arthritis. The Veteran stated at the March 2011 Board hearing that he "cracked" his right hip, possibly because he was trying to keep pressure off of his left leg. Board Hearing Tr. 8, 13. He also testified that he has never been found to have any arthritis condition in the hip. Id. at 7. The Veteran's service treatment records and VA treatment records are silent for any complaints or treatment relating to the right or left hips. As noted above, the Veteran's general examinations from November 2008 to December 2011 show full range of motion in all joints, other than the left knee, with no swelling, tenderness, or warmth. At the February 2012 VA examination, the examiner noted that the Veteran had never been diagnosed with a hip or thigh condition. The Veteran reported that he hurt his right hip at work when he had to shift his weight due to swelling in his left knee. He reported having some right hip pain, but that he has not received treatment for right hip pain since 2000. X-rays showed minimal degenerative changes of the hips. The examiner diagnosed the Veteran with minimal degenerative joint disease. The examiner stated that the Veteran's disorder was less likely than not related to an in-service injury, event or illness, explaining that the Veteran's medical records showed no post-service care for a hip disability or condition and that there was a huge gap in continuity of care between separation from service and treatment in the late 1990s, both in the Veteran's records and his own lay statements. He found no secondary conditions associated with the service-connected left knee, and stated that the degenerative changes to the right hip found on X-ray were not related to the left knee condition, but were instead due to aging. He summarized his findings stating that there was no currently diagnosed hip disability that was etiologically related to service or was caused or aggravated by service-connected internal derangement of the left knee with arthritis. After reviewing the evidence of record, the Board finds that while the Veteran has received a current diagnosis pertaining to the hips, diagnosed by the VA examiner as minimal degenerative changes of the hips, the preponderance of the competent and credible evidence is against both a finding that the disability is related to service or that it was caused or aggravated by his service-connected left knee disability. The Veteran alleges that he has a hip disability which was caused by his service-connected left knee disability. There is not, however, any competent medical evidence from a medical professional supporting this assertion. The most probative medical opinion of record is the report of the February 2012 VA examiner, a competent medical professional with expertise in medical matters who examined the Veteran in person and reviewed the full claims file. He found that the Veteran did not have a hip disability that was caused or aggravated by his service-connected left knee disorder. He afforded full consideration of the Veteran's documented medical history and his assertions, provided adequate rationale for his findings, and responded to the necessary questions. The Board finds that this competent and probative medical opinion is to be afforded great probative weight. See, e.g., Guerrieri, 4 Vet. App. at 470-471. The only evidence indicating that the appellant has a current hip disability secondary to a service-connected left knee disability lies within the lay statements of the Veteran himself. As discussed above, the Veteran is a lay person and is not competent to report on matters such as diagnosis or etiology of a disability such a degenerative joint disease. Questions of medical diagnosis and causation of disabilities not capable of lay observation or sensory perception remain within the province of medical professionals, and are not within the scope of the Veteran's competency. See Kahana, 24 Vet. App. at 438; Jandreau, 492 F.3d 1372; Jones, 7 Vet. App. at 137-38 (1994). Hence, the Veteran's assertions regarding the nature and etiology of his right hip disability beyond his complaints of specific symptoms have little probative value, and the examination report of the February 2012 VA examiner is afforded greater probative weight. The Veteran has only alleged that his hip disability is secondary to his service-connected left knee disability, and not that it was directly incurred in service. Nevertheless, the Board notes that there is also no evidence indicating that a hip disability was incurred in or related to service. The Veteran stated that he only incurred a hip injury after separation from service while working in his civilian employment. See Board Hearing Tr. 8. When the fact of chronicity in service is not adequately supported, as in this case, a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The February 2012 VA examiner opined that the Veteran's hip disability was not incurred in or related to service, and there are no contrary medical opinions to this assertion. There is no evidence indicating that the Veteran had any hip injury in service, no evidence linking his current minimal degenerative joint disease to any event or injury in service, and no evidence indicating that the degenerative joint disease manifested within one year of separation from service. Thus, service connection under a direct or presumptive basis is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For all the above reasons, the evidence indicates that the Veteran did not have any disease or injury in service relating to the hips, and the probative evidence of record does not support a finding that any current hip disability is related to service or is caused or aggravated by his service-connected internal derangement of the left knee with arthritis. Accordingly, the preponderance of the evidence of record is against the claim of entitlement to service connection for a hip disability. In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is again against the appellant's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); See, e.g., Gilbert, 1 Vet. App. at 55-57. V. Back Disability The Veteran also contends that he has a low back disability that was caused by his service-connected internal derangement of the left knee with arthritis. The Veteran stated at the March 2011 Board hearing that his back condition is affected due to altered walking from having his left knee swollen or buckle. Board Hearing Tr. 8. He stated that it is the "lower part of [his] back" that has the pain. The Board notes that while the Veteran's VA treatment records show that he has been diagnosed with a cervical spine disability causing him frequent neck pain, the Veteran's March 2011 testimony and statements to the February 2012 VA examiner clarified that he is not seeking service connection for a cervical spine disorder, but only for a disability to the lower part of his back. Thus, the issue discussed at this time includes only consideration of a disability of the thoracolumbar spine. The Veteran's service treatment records and VA treatment records are silent for any complaints or treatment relating to the lower back. As noted above, the Veteran's general examinations show full range of motion in all joints, other than the left knee, with no swelling, tenderness, or warmth. At the February 2012 VA examination, the examiner found that the Veteran had never been previously diagnosed with a thoracolumbar spine condition. The Veteran reported that his back hurt when he had to stand for a long period of time, but that he has never sought care for the disability. He reported that to treat his back, he will sit down or take pain medication. Range of motion testing found normal range of motion of the thoracolumbar spine, including after repetitive motion, with no objective evidence of painful motion. Examination found no tenderness, guarding, or spasm. Muscle strength and sensory testing was normal. X-rays showed mild disc space narrowing at L4-5, with scattered marginal osteophytes, with normal alignment and vertebral body height was maintained. The examiner diagnosed the Veteran with mild degenerative changes of the lumbar spine, and in a May 2013 addendum to the February 2012 VA examination, the examiner also noted that the Veteran had a diagnosis of mild bilateral sciatica, sensory only, not motor. The examiner opined that the Veteran's disorder was less likely than not related to an in-service injury, event, or illness, as there was no post-service care for a low back disability. He stated that there were no secondary conditions found associated with the service-connected left knee, including a lumbar spine disorder. The examiner found that degenerative changes to the lumbar spine were etiologically associated with aging and not the left knee, and that there was no etiological association between the X-ray findings and military service or the left knee. He stated that there was no currently diagnosed back disability that was related to service or was caused or aggravated by service-connected internal derangement of the left knee with arthritis. Application of the relevant law and regulations to the above evidence warrants a finding that the preponderance of the evidence weighs against granting service connection on a direct or secondary basis for a low back disability. The most competent and probative medical evidence of record, that within the February 2012 VA examination report, again finds that there is no relationship between the Veteran's claimed disability and his military service or his service-connected left knee disability. As noted previously, the Board finds that the February 2012 VA examination was performed by a competent medical professional after a thorough review of the claims file and an in-person examination of the Veteran, and he provided an adequate rationale for his opinion. The Board finds that this competent and probative medical opinion is to be afforded great probative weight. See, e.g., Guerrieri, 4 Vet. App. at 470-471. The lay assertions of the Veteran, as a lay person, that his low back disorder is related to his service-connected left knee disability does not constitute competent and credible evidence sufficient to satisfy this nexus requirement in light of the more probative VA medical opinion discussed above. See Jandreau, 492 F.3d at 1377. As a lay person, the Veteran is not competent to opine on the etiology of a complex medical process such as the development of mild degenerative changes of the lumbar spine. See Kahana, 24 Vet. App. at 438; Jandreau, 492 F.3d 1372; Jones, 7 Vet. App. at 137-38 (1994). Hence, the Veteran's assertions have little probative value, and the examination report of the February 2012 VA examiner is afforded greater probative weight. While the Veteran's primary contention is that his low back disability is secondary to his service-connected left knee disability, the Board has also considered whether service connection may be granted on a direct or presumptive basis. There is no evidence indicating that a low back injury was incurred in service, that any low back disability is related to service, or that any lumbar spine arthritis manifested within one year of separation from active duty. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support the claim; in this case, no such continuity has been shown. 38 C.F.R. § 3.303(b). The February 2012 VA examiner opined that the Veteran's low back disability was not incurred in or related to service, and there are no contrary medical opinions to this assertion. Thus, service connection under a direct or presumptive basis is not warranted. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For the foregoing reasons, the preponderance of the evidence is against the claim for entitlement to service connection for a low back disability on a direct or secondary basis. The benefit of the doubt rule is not applicable, and the claim must be denied. See 38 U.S.C.A. § 5107(b); See, e.g., Gilbert, 1 Vet. App. at 55-57. VI. Increased Rating for Left Knee Disability In February 2007, the Veteran submitted a claim for an increased rating for his service-connected internal derangement of the left knee with arthritis. He contends, essentially, that his left knee disability has become worse and warrants a rating higher than the 20 percent currently assigned. The Veteran's VA treatment records show occasional complaints of pain in his left knee which was tender to the touch, but no physical examinations of his knee. In June 2008, the Veteran reported that his left knee was sensitive to the touch, but that he "does not want to know what's going on in there and does not want any intervention." It was noted that he could walk on it without difficulty. At a March 2007 VA examination, the Veteran reported having swelling and that his left knee "tends to give way." He reported pain, weakness, stiffness, instability, giving way, and swelling. He reported that he has been out of work since 2000 when his company closed, and had no other functional limitation due to his knee or flare-ups of the knee. On physical examination, the examiner found that the knee was tender medially, laterally, anteriorly. It had crepitus and swelling, but no laxity. Extension was to 0 degrees, with pain, and flexion was 0-120 degrees actively, also with pain. There was no decrease in the range of motion or function additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use of the joint. The Veteran was also afforded a VA examination in October 2013. The examiner reviewed the claims file and performed an in-person examination of the Veteran. He diagnosed the Veteran with left knee degenerative joint disease and chondromalacia. The Veteran reported having occasional swelling of his left knees and that some days it hurts and swells more than others. Range of motion testing found left knee flexion to 120 degrees, including after repetitive motion, with objective evidence of painful motion at 110 degrees. There was no objective evidence of painful motion on extension, and post-test extension of the left knee was 0 degrees of any degree of hyperextension. The Veteran had tenderness or pain to palpation of the left knee, with normal muscle strength and stability. There was no history or evidence of patellar subluxation or other knee condition. The Veteran did not use any assistive devices to ambulate. X-rays showed osteoarthritis. The examiner noted that the Veteran's let knee disorder would cause difficulties with occupational duties requiring repetitive squatting, but that he could sustain duties of a sedentary nature. Based on this evidence, the record preponderates against entitlement to a rating in excess of 20 percent for internal derangement of the left knee with arthritis throughout the entire rating period. The assignment of a 20 percent rating under Diagnostic Code 5258 is already the maximum allowable rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258. The Board must therefore consider whether any higher rating is allowable under a comparable and similarly appropriate rating code or whether a separating compensable rating may be assigned during this time period for symptomatology not overlapping with that described above. See 38 C.F.R. §§ 4.14, 4.40; VAOPGCPREC 9-04, 69 Fed. Reg. 59,990 (2004). The Board acknowledges that separate ratings under the Diagnostic Codes pertaining to the knees may be assigned for disability of the same joint, if none of the symptomatology on which each rating is based is duplicative or overlapping. See id. For example, VA General Counsel has held that a claimant who has both limitation of motion arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 9-98; 63 Fed. Reg. 56704 (1998); VAOPGCPREC 23-97; 62 Fed. Reg. 63604 (1997). In this case, however, this rule is found to be inapplicable. The Veteran has not been found to have any lateral instability or subluxation. The Veteran has been found to have slight limitation in his flexion range of motion in the left knee, including due to pain. The Board finds that a separate rating for this symptom would, however, be overlapping with the current rating assigned. The Veteran's symptoms of pain and locking are specifically contemplated in the rating criteria for Diagnostic Code 5258. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Since Diagnostic Code 5258 contemplated locking, a form of limited motion, separate evaluations may not be assigned for limited motion, as such would violate the rule against pyramiding. 38 C.F.R. § 4.14. There is also no rating higher than 20 percent that can be assigned through an alternate Diagnostic Code. See 38 C.F.R. § 4.20. The Veteran's left knee extension has at all times been found to be normal, and his extension has been found to be limited to no worse than 110 degrees, including with consideration of limitation due to pain. At no time has the Veteran demonstrated any limitation of motion of the right knee which would limit flexion or extension to a degree which would warrant a compensable rating. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. When a Veteran has been diagnosed with arthritis, a 10 percent rating can be assigned even when the degree of limitation is otherwise noncompensable under 38 C.F.R. § 4.71a, Diagnostic Code 5003. However, as this would result in only a 10 percent rating, it would not be a greater benefit than the one currently assigned. There has also been no evidence at any time of subluxation or meniscal tear, cartilage dislocation, genu recurvatum, or ankylosis, and the Veteran has not indicated that he has ever been found to have any of these symptoms. The evidence therefore preponderates against a higher or separate rating for other left knee impairment under any other possibly applicable rating criteria. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256-5259, 5263. The Board notes that functional loss due to pain, weakness, excess fatigability, or incoordination has been taken into consideration. DeLuca, 8 Vet. App. at 206. The Veteran has reported having significant pain in his left knee, and the October 2013 VA examination did find slightly decreased range of motion due to pain. The Board acknowledges that the Veteran experiences pain, and has considered these factors in the rating assigned. However, the rating criteria under Diagnostic Code 5258 specifically contemplate pain, and therefore no increased rating would be warranted on the basis of this symptom alone. Without clinical evidence indicating further additional functional limitation, the Board is unable to find that the Veteran's pain is so disabling as to actually or effectively limit left knee function to such an extent as to warrant assignment of a higher rating. In reaching this decision, the Board has considered the Veteran's lay statements regarding the functional impact of his left knee disability. The appellant is competent to report his own observations with regard to the severity of his left knee disability, including reports of pain, swelling, and limited mobility. See Jandreau, 492 F.3d at 1376-77. The Board finds his statements to be credible and consistent with the rating assigned. To the extent he argues that his symptomatology is more severe, his statements must be weighed against the other evidence of record. Here, the specific examination findings of trained health care professionals are of greater probative weight than the Veteran's more general lay assertions. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). 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. See Fisher, 4 Vet. App. at 60. Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology and provide for additional or more severe symptoms than currently shown by the evidence. The rating criteria specifically take into account episodes of pain, which is the Veteran's primary complaint regarding his left knee symptoms. He has been noted to be able to ambulate normally on multiple occasions, and there is no evidence that his left knee disability has ever had any impact on his occupational functioning. The record does not show that the Veteran has required any hospitalization for his left knee disability, nor is there evidence in the medical records of an exceptional or unusual clinical picture. The Veteran's disability picture is sufficiently contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun, 22 Vet. App. at 115. Consequently, referral for extraschedular consideration is not warranted. In sum, there is no basis for assignment of a rating in excess of 20 percent for internal derangement of the left knee with arthritis at any time during the current appeal. In reaching this decision the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); See, e.g., Gilbert, 1 Vet. App. at 55-57. ORDER Entitlement to service connection for a right knee disability, to include on a secondary basis, is denied. Entitlement to service connection for a hip disability, to include on a secondary basis, is denied. Entitlement to service connection for a low back disability, to include on a secondary basis, is denied. Entitlement to an increased rating for internal derangement of the left knee with arthritis, currently evaluated as 20 percent disabling, is denied. REMAND The Veteran contends that he has a chronic headache disorder which was either caused by exposure to Agent Orange in service or is secondary to his service-connected diabetes mellitus or peripheral neuropathy. At the March 2011 Board hearing, he testified that his peripheral neuropathy causes his neck to pull to the right, and that this causes headaches. Board Hearing Tr. 5. The February 2012 VA examiner diagnosed the Veteran with uncomplicated headache, non-migrainous type, and he opined that the Veteran's headaches were not etiologically related to his service-connected diabetes mellitus. After this examination occurred, however, the Veteran was treated by a VA neurologist in July 2012 for occipital headache with some neck pain, likely secondary to chronic tension headaches. He reported having chronic headaches ever since he was in Vietnam and described the pain as "persistent over the years and gradually worsened in intensity with intermittent severe exacerbations." Additionally, the Veteran was granted entitlement to service connection for peripheral neuropathy of the bilateral upper extremities in August 2013. The Board therefore finds that a new VA examination is needed, in order to reevaluate whether the Veteran has a current diagnosis of any current headache disorder and to determine the relationship, if any, between his now service-connected peripheral neuropathy and his headaches. Accordingly, the case is REMANDED for the following action: 1. Arrange for a VA examination of the Veteran to determine the nature and etiology of his claimed headache disorder. All records in Virtual VA and VBMS must be provided to the examiner, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. All indicated tests should be accomplished, and all clinical findings reported in detail. The examiner should respond to the following: a) Does the Veteran have a current diagnosis of a headache disorder? Please discuss the July 2012 findings of the Veteran's neurologist that he has occipital headaches with neck pain secondary to chronic tension headaches and the Veteran's physical therapy pertaining to neck pain and pulling. b) Is it at least as likely as not (a 50 percent probability or greater) that any diagnosed headache disorder had its onset during service, was caused by service, or is otherwise related to any event in service? Please discuss the service treatment record showing that the Veteran complained of pain in the back of his head after hitting his head in November 1964 and the Veteran's lay statements of having continuous intermittent headaches since service until the present. c) Is it at least as likely as not that any diagnosed headache disorder was caused by or aggravated (worsened beyond the natural progression) by his service-connected diabetes mellitus or peripheral neuropathy? Please discuss the Veteran's contention that his peripheral neuropathy causes "pulling" on his neck which triggers headaches. The examiner should set forth all examination findings, together with the complete rationale for the comments and opinions expressed. 2. Thereafter, the AOJ should readjudicate the issue. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided with a Supplemental Statement of the Case and afforded the appropriate opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals 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 2014). ____________________________________________ Alexandra P. Simpson Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs