Citation Nr: 1603545 Decision Date: 02/02/16 Archive Date: 02/11/16 DOCKET NO. 09-03 630 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Evaluation of tricompartmental degenerative arthritis of the patellofemoral joint of the left knee, initially rated as noncompensable. 2. Evaluation of partial ankylosis of the right fifth finger, distal interphalangeal joint, initially rated as noncompensable. 3. Entitlement to service connection for a right knee disorder, including as secondary to the service-connected left knee disorder. 4. Entitlement to service connection for a right foot disorder. 5. Entitlement to service connection for a back disorder. 6. Entitlement to service connection for hemorrhoids. 7. Entitlement to service connection for a skin disorder. 8. Entitlement to service connection for tinnitus. 9. Entitlement to a total rating for compensation on the basis of individual unemployability. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Hallie E. Brokowsky, Counsel INTRODUCTION This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. The Veteran served on active duty from March 1965 to December 1976. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The November 2007 rating decision granted service connection for the left knee and right 5th finger, and assigned a noncompensable disability rating for each, effective May 16, 2007; this rating decision also denied entitlement to service connection for a right knee disorder, a right foot disorder, a back disorder, a skin disorder, hemorrhoids, and tinnitus. In December 2012, the Board remanded several issues and denied the Veteran's claims for service connection for a right knee disability, a right foot disability, a back disability, hemorrhoids, and a skin condition. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claim (Court). In December 2013, the Court granted the parties Joint Motion for Remand (JMR), vacating the December 2012 decision and remanding the matter for further development. In July 2014, the Board remanded the Veteran's claims for additional development in accordance with the JMR and for compliance with the December 2012 remand. Following completion of the requested development and due process considerations, a supplemental statement of the case was issued in December 2014. The claims were returned to the Board. In his January 2009 Substantive Appeal, the Veteran requested a hearing before a Veterans Law Judge of the Board. In July 2010, he was properly notified that a hearing had been scheduled in September 2010. However, he failed to appear for it, and has not provided and explanation for his absence or requested to reschedule the hearing. Therefore, the Board will proceed to a decision on his appeal as if his request for a hearing was withdrawn. See 38 C.F.R. § 20.704(d) (2015). The issues of entitlement to service connection for tinnitus and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Tricompartmental arthritis of the patellofemoral joint of the left knee is manifested by painful and limited motion; remaining functional flexion was better than 45 degrees and extension was full. 2. Partial ankylosis of the right fifth finger, distal interphalangeal joint, is manifested by limitation of motion of the right little finger and a less than one-inch gap between the proximal transverse crease of the palm. 3. A right knee disorder was not manifest in service or within one year of separation. A right knee disorder is not attributable to service. 4. A right knee disorder is not related (causation or aggravation) to a service-connected disease or injury. 5. A right foot disorder was not manifest in service and is not attributable to service. 6. A back disorder was not manifest in service or within one year of separation. A back disorder is not attributable to service. 7. Hemorrhoids were not manifest in service and are not attributable to service. 8. A skin disorder was not manifest in service and is not attributable to service. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 10 percent, but no higher, for tricompartmental degenerative arthritis of the patellofemoral joint of the left knee have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260 (2015). 2. The criteria for a compensable evaluation for partial ankylosis of the right fifth finger, distal interphalangeal joint, are not met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5227 (2015). 3. A right knee disorder was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2015). 4. A right knee disorder is not proximately due to or a result of a service-connected disease or injury. 38 C.F.R. §§ 3.102, 3.159, 3.310 (2015). 5. A right foot disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2015). 6. A back disorder was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2015). 7. Hemorrhoids were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2015). 8. A skin disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the agency of original jurisdiction (AOJ) issued notice letters to the Veteran. These letters explained the evidence necessary to substantiate the Veteran's claims for service connection, as well as the legal criteria for entitlement to such benefits; the Veteran's claims for increased disability ratings are downstream from his initial claim for service connection. Nevertheless, the letters also informed him of his and VA's respective duties for obtaining evidence. The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice. As such, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The claims file contains the Veteran's available service treatment records, reports of post-service treatment, and the Veteran's own statements in support of his claims. The Veteran was also afforded VA examinations responsive to the claims for increased ratings for the left knee and right 5th finger. The examination reports contain all the findings needed to rate the Veteran's service-connected disabilities on appeal, including history and clinical evaluation. The Veteran was also afforded VA examinations responsive to the claims for service connection of a right knee disorder, right foot disorder, back disorder, hemorrhoids, and a skin disorder. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). The opinions were conducted by a medical professional, following thorough examination of the Veteran, solicitation of history, and review of the claims file. The Board has reviewed the Veteran's statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the VCAA duties to notify and assist have been met. Disability Evaluations Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the service-connected left knee disability and right 5th finger disability have not materially changed and uniform evaluations are warranted for the entire rating period on appeal. In addition, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Left Knee The Veteran is currently rated for his tricompartmental degenerative arthritis of the patellofemoral joint of the left knee pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5010-5257. See 38 C.F.R. § 4.20. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2015). The Board observes that the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Here, the Board is amending the Diagnostic Code assigned for his tricompartmental degenerative arthritis of the patellofemoral joint of the left knee to reflect that the Veteran has been shown to have arthritis of the left knee. In short, the more appropriate code for rating the Veteran's tricompartmental degenerative arthritis of the patellofemoral joint of the left knee is Diagnostic Code 5003, for degenerative arthritis. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Diagnostic Code 5003 provides that degenerative arthritis substantiated by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. A 20 percent evaluation is warranted for x-ray evidence of involvement of 2 or more major or minor joints, with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a, DC 5003. However, the Veteran has not reported experiencing any incapacitating exacerbations. The appropriate diagnostic codes for the knee joint are DCs 5260 and 5261, applicable to limitation of flexion and extension of the leg, respectively. Under DC 5260, limitation of flexion of a leg warrants a noncompensable rating when flexion is limited to 60 degrees. A 10 percent rating is warranted if flexion is limited to 45 degrees, and a 20 percent rating is warranted if flexion is limited to 30 degrees. Flexion that is limited to 15 degrees warrants a 30 percent rating. Under DC 5261, limitation of extension of a leg is noncompensable when extension is limited to 5 degrees, warrants a 10 percent rating when it is limited to 10 degrees, a 20 percent rating when it is limited to 15 degrees, a 30 percent rating when limited to 20 degrees, a 40 percent rating when limited to 30 degrees, and a 50 percent rating when limited to 45 degrees. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. VA's General Counsel has held that separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. VAOPGCPREC 9-2004 (2004). As will be discussed below, a separate evaluation is not warranted, as the Veteran has full extension of the left knee during the applicable rating period. In VAOGCPREC 23-97 (July 1, 1997; revised July 24, 1997), VA's General Counsel held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, respectively. However, there is no evidence of instability or subluxation of the left knee; testing for instability and subluxation of the knee was negative at the October 2007 and November 2013 VA examinations. After a review of all the evidence, the Board finds that the Veteran's service-connected tricompartmental degenerative arthritis of the patellofemoral joint of the left knee more nearly approximates the criteria for a 10 percent disability evaluation. This evaluation contemplates pathology productive of painful motion, consistent with the functional equivalent of limitation of flexion to 45 degrees. In order to warrant a higher evaluation, there must be the functional equivalent of limitation of flexion to 30 degrees (Diagnostic Code 5260). The Board observes that the Veteran had limitation of motion at the October 2007 and November 2013 VA examinations; flexion was 130 degrees, and repetitive motion did not change the range of motion. The Board accepts the lay evidence that the Veteran experiences pain. Similarly, the Board accepts the evidence that he has limitation of flexion impacted by pain. However, such evidence does not establish that flexion is functionally limited to less than 45 degrees. Such evidence establishes that he is no more than 10 percent disabled based upon limited flexion. Stated differently, although there may have been pain at 5 degrees, such pain did not functionally limit flexion to less than 45 degrees. To the contrary, the Veteran had range of motion within normal limits. Regarding the other plane of motion, the October 2007 and November 2013 VA examinations disclosed that the Veteran had full extension, to 0 degrees, of the left knee. Thus, the Veteran is not entitled to a separate disability rating under Diagnostic Code 5261 for the left knee during the applicable rating period, as he does not have compensable limitation of extension. There is no indication that he has additional functional impairment, above and beyond the 10-percent level for tricompartmental degenerative arthritis of the patellofemoral joint of the left knee, which would support a higher rating for the rating period on appeal. In this regard, the Board points out that the Veteran's VA examinations and treatment records were repeatedly negative for objective evidence of incoordination, abnormal movement, or deformity. See DeLuca, supra. There was crepitus on examination in November 2013, but there was no evidence of weakness, fatigue, incoordination, deformity, or reduced muscle strength at either VA examination. Although the Veteran reported additional limitation during flare-ups of pain, the extent of such limitation was not shown upon examination. See DeLuca, citing 38 C.F.R. §§ 4.40, 4.45, and 4.59. Here, neither the medical nor lay evidence suggests that his limitation approximated 30 degrees of flexion. As a result, the 10 percent rating for tricompartmental degenerative arthritis of the patellofemoral joint of the left knee adequately compensates him for the extent of his pain during the applicable rating period. Additionally, the Board has considered the claim for an increased rating for the entire rating period on appeal under several other diagnostic codes used to evaluate the knee. There is no evidence of ankylosis of the left knee joint or any impairment of the tibia or fibula of the left leg to warrant consideration under either Diagnostic Code 5256 or 5262. Under Diagnostic Code 5258, a 20 percent evaluation is for assignment where there is dislocation of the semilunar cartilage with episodes of "locking," pain, and effusion into the joint; examination was negative for patellar subluxation or dislocation. Regardless, the Veteran is not entitled to ratings under both DC 5260 and DC 5258 for the left knee. See, generally, VAOPGCPREC 9-98. Therefore, neither higher nor separate evaluations are warranted under either code 5258 or 5259. Right 5th Finger The Veteran's partial ankylosis of the right fifth finger, distal interphalangeal joint, is assigned a noncompensable disability evaluation pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5227. Under this Code, a noncompensable evaluation is for assignment where there is favorable or unfavorable ankylosis of the little finger. The Board points out that the October 2007 and November 2013 VA examination reports indicate that the Veteran is left-handed. After a review of all the evidence, the Board finds that the weight of the evidence demonstrates that the Veteran's service-connected partial ankylosis of the right fifth finger, distal interphalangeal joint, is most consistent with the currently assigned noncompensable disability evaluation and that an increased, compensable disability evaluation is not warranted. At the October 2007 and November 2013 VA examinations, the Veteran complained of pain. Physical examination showed that the Veteran had limitation of motion, with a less than one inch gap between the fingers and the proximal transverse crease of the palm. There was pain on motion of the distal interphalangeal joint, but without decreased range of motion and strength of the right hand. The Board observes that the Veteran has limitation of motion of the right 5th finger, but under Diagnostic Code 5227, only a noncompensable disability evaluation is warranted for any limitation of motion of the little finger; there is no higher evaluation available. Accordingly, the Veteran's symptomatology for the period on appeal most closely approximates the criteria for the currently assigned noncompensable disability evaluation for his partial ankylosis of the right fifth finger, distal interphalangeal joint. See 38 C.F.R. § 4.71a, Diagnostic Codes 5227, 5230. The Board has considered whether additional functional impairment due to factors such as pain, weakness and fatigability demonstrate additional limitation of motion or function to warrant a higher rating. See 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca at 206-07. The Board has specifically considered 38 C.F.R. § 4.59, which provides for a minimal compensable evaluation for the joint under certain circumstances; however, there is no minimum compensable evaluation for the joint at issue. To the extent that the Veteran claims that his pain is the equivalent of limited motion, the Board finds that the Veteran's subjective complaints of pain have been contemplated in the current rating assignment, as the current rating is based on the objectively demonstrated reduced motion. According to the October 2007 and November 2013 VA examination reports, the Veteran did not demonstrate any additional functional impairment in response to pain, including incoordination, weakness, or fatigability, beyond which was reflected in the examination report. Therefore, the lay and medical evidence demonstrates that the Veteran's symptoms do not result in additional functional limitation to a degree that would support a compensable rating. Extraschedular Considerations As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. 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. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptoms of the Veteran's tricompartmental degenerative arthritis of the patellofemoral joint of the left knee and partial ankylosis of the right 5th finger, distal interphalangeal joint, are fully contemplated by the applicable rating criteria. As shown above, the criteria include symptoms, each of which were addressed in the treatment records and VA examination reports, which provided the basis for the disability ratings that were assigned. The Veteran primarily complained of pain and reduced range of motion, which were clearly contemplated in the currently assigned disability evaluations. In any event, the evidence does not reflect that there has been frequent hospitalization or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. Additionally, there is no indication that the Veteran's tricompartmental degenerative arthritis of the patellofemoral joint of the left knee and partial ankylosis of the right 5th finger, distal interphalangeal joint, standing alone, had an impact on his employment beyond that which is contemplated by the rating criteria. Therefore, referral for consideration of an extraschedular rating for the Veteran's tricompartmental degenerative arthritis of the patellofemoral joint of the left knee and partial ankylosis of the right 5th finger, distal interphalangeal joint, is not warranted. 38 C.F.R. § 3.321(b)(1). Finally, the Board notes that under Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. In the absence of exceptional factors associated with tricompartmental degenerative arthritis of the patellofemoral joint of the left knee and partial ankylosis of the right 5th finger, distal interphalangeal joint, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2015). 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 be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As arthritis is a chronic disease for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA laws and regulations provide that, if a Veteran was exposed to Agent Orange during service, certain listed diseases are presumptively service-connected. 38 U.S.C.A. § 1116(a)(1); 38 C.F.R. § 3.309(e). A Veteran who "served in the Republic of Vietnam" between January 9, 1962 and May 7, 1975 is presumed to have been exposed during such service to Agent Orange. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The listed diseases are: AL amyloidosis, chloracne or other acneform disease consistent with chloracne, Type II diabetes mellitus (adult-onset diabetes), Hodgkin's disease, ischemic heart disease, chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx or trachea); and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). In addition, the Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); Notice, 61 Fed. Reg. 41, 442-49 (1996); Notice, 72 Fed. Reg. 32,395-32,407 (Jun. 12, 2007); Notice, 74 Fed. Reg. 21,258-21,260 (May 7, 2009); Notice, 75 Fed. Reg. 32540 (June 8, 2010). The fact that a Veteran cannot establish entitlement to service connection on a presumptive basis does not preclude him from establishing entitlement on a direct incurrence or other basis. See 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.304(d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) (Radiation Compensation Act does not preclude a veteran from establishing service connection with proof of actual direct causation). The Veteran's multiple DD Form 214s reflect that his military occupational specialty involved water transport, including as a boatswain's mate. The DD Form 214s also reflect that the Veteran had service in Vietnam and that he was awarded the Combat Action Ribbon and the Navy Achievement Medal with Combat "V." Thus, the evidence indicates that he engaged in combat with the enemy and the combat provisions of 38 U.S.C.A. § 1154 (West 2014) are potentially applicable. Hemorrhoids, Right Foot Disorder, Back Disorder The Veteran claims that he has hemorrhoids, a right foot disorder, and a back disorder which are related to his active service. At the outset, the Board notes that the Veteran does not claim, and the evidence does not reflect, that his disabilities are the result of combat with the enemy. Therefore, the combat provisions of 38 U.S.C.A. § 1154 are not applicable. The Board acknowledges that the Veteran's service treatment records show complaints of right foot pain and back pain. In particular, a June 1969 service treatment record noted that the Veteran had blisters on his feet. A 1976 service treatment record noted that the Veteran injured his right foot after dropping 50 pounds on it. A November 1973 service treatment record noted that the Veteran had low back pain with onset related to lifting heavy boxes. January 1974, September 1974, January 1975, August 1975, February 1976, and October 1976 service treatment records reflect complaints of or treatment for back pain. The Board observes that the Veteran did not report any complaints of a skin disorder or hemorrhoids during service. Nonetheless, a June 1967 service treatment record noted that the Veteran had a pilonidal cyst, and a July 1976 service treatment record reflects a rectal strain. The Board notes that, at his November 1976 separation examination, the Veteran expressly denied experiencing rectal disease or piles, stomach or intestinal trouble, arthritis and bursitis, foot trouble, skin disease, and swollen or painful joints. The November 1976 separation examination report indicates that physical examination of the Veteran's spine, lower extremities, musculoskeletal system, and skin were normal; examination of the anus and rectum reflected that there was a pilonidal sinus. The Board acknowledges that the Veteran, in a March 2008 statement, asserted that he performed heavy lifting in service, which caused his hemorrhoids. The Board also acknowledges that the Veteran, in a March 2008 statement, reported that he has had chronic right foot pain since his in-service injury. The Board notes that, whether service connection is claimed on direct or secondary basis, a necessary element for establishing such a claim is the existence of current disability. In this case, the Veteran must show that he currently has hemorrhoids, a right foot disorder, and a back disorder due to disease or injury in service. See Sanchez-Benitez v. Principi, 259 F.3d 1356, 1361-1362 (Fed. Cir. 2001). The Board finds that the weight of the evidence is against the existence of hemorrhoids, a right foot disorder, and a back disorder. There is no evidence, including the Veteran's own statements, reflecting that he has been treated or diagnosed with any disorders related to the claims. The Veteran's post-service treatment records do not reflect any related complaints or treatment. In this regard, the Veteran has not provided any medical evidence of treatment, complaints, or diagnoses related to any hemorrhoids, a right foot disorder, or a back disorder in the years since his active duty. In fact, the Veteran has made no assertions of hemorrhoids, right foot disorder, and back disorder related to his active duty except as it relates to his claims for service connection. See Pond v. West, 12 Vet. App. 341 (1999). As such, the Board finds that the Veteran's report of on-going problems to be inconsistent with the record and not credible. To the extent that the Veteran reported a history of hemorrhoids, a right foot disorder, and a back disorder during and since service, the Board notes that he is competent to report symptoms and whether he has received diagnoses, including when he was first treated or diagnosed. No complaints or diagnoses related to his hemorrhoids were reported, however, and other than the aforementioned in-service treatment for his right foot and back, there have been no related complaints or diagnoses. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). To the extent that there are lay statements asserting that the Veteran has a hemorrhoids, a right foot disorder, and a back disorder, related to an in-service event, injury, or illness, the Board finds that the probative value of the general lay assertions are outweighed by the absence of medical evidence of record showing any hemorrhoids, right foot disorder, or back disorder. Moreover, nothing suggests a relationship between his service and the claimed disorders. The Board finds that the probative value of the general lay assertions are outweighed by the specific, reasoned opinions of the October 2007 and November 2013 VA examination reports, and the November 2013 VA medical opinion, as well as the clinical evidence of record. The remote assertions of the Veteran are inconsistent with the clinical evidence of record, which does not demonstrate complaints, treatment, or a diagnosis related to his claimed hemorrhoids, right foot disorder, and back disorder. In this regard, the Board points out that the opinions of the VA examiners were specific and well-reasoned. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The VA examiners found that the Veteran did not have hemorrhoids, a right foot disorder, and a back disorder, and that the Veteran's right foot and back complaints in service were acute episodes associated with specific activities and that clinical evaluations were normal. The VA examiners also explained the reasons for the conclusion that the Veteran did not have hemorrhoids and that the Veteran's strain and pilonidal cyst in service were not productive of hemorrhoids based on an accurate characterization of the evidence of record; the VA examiners considered statements from the Veteran. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has noted that in order for a veteran to qualify for entitlement to compensation under those statutes, he or she must prove existence of a disability, and one that has resulted from a disease or injury that occurred in the line of duty. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). Here, we are faced with nothing more than post-service complaints of hemorrhoids, a right foot disorder, and a back disorder. He has not presented competent evidence of post-service pathology (diagnosis) to account for the lay complaints. The Board finds that the preponderance of the evidence is against the claims for hemorrhoids, a right foot disorder, and a back disorder. The benefit-of-the-doubt doctrine is therefore not for application, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Skin Disorder, Right Knee Disorder Based on the evidence of record, the Veteran's claim of service connection for a skin disorder and a right knee disorder, including as secondary to Agent Orange exposure and a service-connected left knee disorder, respectively, must be denied. Here, no arthritis of the right knee or chloracne was "noted" or identified during service or within one year of separation. Additionally, there is nothing to suggest that there were characteristic manifestations sufficient to identify the claimed right knee and skin disorders during service. 38 C.F.R. § 3.303(b). The Board points out that the Veteran did not have any complaints, treatment, or diagnoses related to his right knee during his service. The Board acknowledges that a July 1975 service treatment note reflects that the Veteran was treated for a rash on his groin. However, the Veteran denied experiencing skin disease and knee trouble at separation. His separation examination report reflects that physical evaluation of his skin, lower extremities, and musculoskeletal system was normal. In March 2008, the Veteran asserted that he has a rash that comes and goes, and that he had itchy outbreaks ever since service. In the February 2008 Notice of Disagreement (NOD), the Veteran asserted that he hurt his right knee in service, but did not receive treatment. In a March 2008 statement, he asserted that his service treatment records show a bilateral knee injury and that he performed heavy lifting in service. The Board acknowledges that an April 1972 service treatment record reflects that the Veteran was in a motorcycle accident and injured his left knee. The December 2013 JMR indicates that the Veteran asserts that he had chronic knee pain since service. The Veteran is competent to report symptoms and diagnoses of a right knee disorder and skin disorder, and when his symptoms were first identified. See Kahana, supra. However, none of the post-service treatment records reflect complaints, treatment, or diagnoses of a right knee disorder, including arthritis, or a skin disorder, including an acneform disease, within one year of service. Moreover, his statements, even if accepted as credible, do not establish a nexus to his service. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). The weight of the evidence reflects that the Veteran's skin disorder, diagnosed as a hyperkeratotic papular growth, is unrelated to his service. The Board notes that the November 2013 VA examiner explained that the hyperkeratotic papular growth is not caused by chloracne or other acneform disease; the VA examiner found that this growth is unrelated to the Veteran's service, including any Agent Orange exposure in service. In this regard, the Board reiterates that the Veteran denied experiencing skin disease at separation and points out that post-service treatment records do not demonstrate any treatment for a skin disorder. The Board notes that the Veteran reported to the VA examiner that he experienced intermittent rashes, but that no evidence of a rash or skin disorder other than the aforementioned hyperkeratotic papular growth were found on examination. Additionally, the November VA knee examination report indicates that the Veteran does not currently have an objective right knee disability. The report indicates that the Veteran reported a diagnosis of right arthralgia. The VA examiner found that the Veteran's claimed right knee disorder was not related to his service, including his service-connected left knee disorder. Following an examination and a review of the Veteran's electronic claims file, the VA examiner concluded that the Veteran's claimed right knee disorder is not likely related to his service. According to the VA examiner, his claimed right knee disorder did not begin during service and is not due to any incident of service, including the April 1972 motorcycle accident with a documented left knee injury. The VA examiner acknowledged that the Veteran had a right knee laceration in 1974, but that there were no residuals, and the service treatment records do not reflect any right knee involvement in the March 1972 motorcycle accident. The VA examiner notes that the Veteran reported that his right knee pain began approximately 10 years earlier, and that a private physician did x-rays, which showed arthritis; the VA examiner noted that an attempt was made to get the x-ray, but that a nurse at the physician's office could not find any imaging for the right knee. The November 2013 VA examiners noted that the absence of related complaints in the years since service indicated that there is no relationship between his current complaints and his service. Specifically, the November 2013 VA knee examiner addressed the Veteran's assertion that his right knee was injured while lifting heavy loads during active duty, and found that heavy living could cause acute pain in joints due to mechanical strain, but that such episodes are transient and limited to the activities at that time, and resolved with rest and medication. The VA examiner pointed out that there is no credible scientific data to suggest they cause significant permanent pathological disabilities. Moreover, the VA skin examiner noted that the Veteran reported that his hyperkeratotic papular growth began approximately 20 years earlier, which is over 15 years after his service, and that there was no objective medical evidence of any related complaints in the years after his service. As such, the Board finds that the Veteran's report of on-going problems to be inconsistent with the record and not credible. See Madden v. Gober, 125 F.3d 1477, 1481 (1997). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board finds that the probative value of the Veteran's general lay assertions are outweighed by the specific, reasoned opinion provided in the VA examination reports and the clinical evidence of record. The VA examiners, in determining that the Veteran's claimed right knee and skin disorders were not related to his service, are entitled to greater probative weight than the more general lay assertions of the Veteran, even assuming those lay assertions were competent. The Board notes that the opinions of the VA examiners are also consistent with the medical evidence of record, which does not demonstrate that the Veteran's claimed right knee and skin disorders are related to his service. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). For the foregoing reasons, the preponderance of the evidence is against the claims for service connection of a right knee disorder and a skin disorder. The benefit-of-the-doubt doctrine is therefore not for application, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER Entitlement to an initial 10 percent disability evaluation for tricompartmental degenerative arthritis of the patellofemoral joint of the left knee, but no more, is granted, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to an initial compensable disability rating for partial ankylosis of the right fifth finger, distal interphalangeal joint, is denied. Service connection for a right knee disorder is denied. Service connection for a right foot disorder is denied. Service connection for a back disorder is denied. Service connection for hemorrhoids is denied. Service connection for a skin disorder is denied. REMAND A claim for increased evaluation includes a claim for a TDIU where there are allegations of worsening disability and related unemployability. Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, in multiple statements, the Veteran alleged that his service-connected disabilities preclude him from obtaining or maintaining gainful employment. Therefore, a TDIU claim is raised by the record in this case. A Board remand confers on the Veteran the right to compliance with the remand orders. See Stegall v. West, 11 Vet. App. 268 (1998). Based on a review of the examination reports, it appears that the November 2013 VA examination is inadequate. The report does not address the Board's instructions in the December 2012 and July 2014 Board remands. In this regard, the December 2012 and July 2014 Board remands requested clarification of the Veteran's claim for service connection of tinnitus, including a discussion of the etiology of his claimed tinnitus. The Board observes that the Veteran's statements represent competent evidence of continuity of symptomatology (ringing in the ears is a lay-observable symptom). In a September 2014 VA examination report, the VA examiner noted that there was a threshold shift during service and that high-frequency tinnitus usually accompanies such hearing loss. Additionally, the Board observes that the September 2014 VA examination may constitute new and material evidence to reopen the Veteran's previously denied claim of entitlement to service connection for bilateral hearing loss disability, and that the Veteran's assertions at that examination may constitute an application to reopen. Ordinarily, the Board would refer such an application to the RO via the AMC, but given the clarification required as to the claim for service connection of tinnitus, the Board finds that the issue of whether new and material evidence has been received to reopen the claim of service connection for bilateral hearing loss disability is inextricably intertwined with the claim for service connection of tinnitus, and thus, must be remanded. See, e.g., Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a VCAA notice letter pertaining to a claim for entitlement to TDIU, and allow for a reasonable period to respond. The RO/AMC should request that the Veteran provide sufficient information and authorization to enable it to obtain any additional evidence pertinent to the claim for TDIU. After completing all indicated development, the RO should adjudicate the claim for TDIU in light of all the evidence of record. 2. Schedule the Veteran for an audiology examination with an appropriate clinician. The entire claims file, including a copy of this remand must be made available to the examiner for review. The examiner must take and record a detailed history from the Veteran. The examiner is advised that that because the Veteran was in combat, noise exposure is conceded. The examiner is also advised that a lay person is capable of observing ringing in the ears. In providing the requested opinion, the examiner must specifically address the Veteran's lay assertions, as laid out in the claims file; such prior statements cannot be disregarded solely due to lack of contemporaneous medical evidence and the report must reflect review of the lay statements. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral tinnitus began during active service or is related to any incident of service to include noise exposure. A complete rationale should accompany each opinion provided 3. The RO must review the claims file and ensure that the foregoing development actions have been completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 4. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative must be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. 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). ______________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs