Citation Nr: 1753532 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 13-26 485 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for a right knee musculoligamentous strain. 2. Entitlement to an increased initial disability rating for posttraumatic stress disorder (PTSD), rated as 50 percent disabling prior to January 2, 2016, and 70 percent thereafter. 3. Entitlement to service connection for a neck disability, to include a mechanical cervical strain. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD A. Fagan, Counsel INTRODUCTION The Veteran served on active duty from July 1991 to July 1995. This matter is before the Board of Veterans' Appeals (Board) on appeal from September 2011 and June 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In October 2015, the Board in pertinent part denied entitlement to an increased rating for the right knee disability, and remanded the issues of entitlement to service connection for a neck disability, an increased rating for PTSD, and an inferred claim of entitlement to a TDIU. The Veteran appealed the Board's denial of the right knee increased rating claim to the United States Court of Appeals for Veterans Claims (Court). In March 2016, the Court granted a Joint Motion for Partial Remand, which set aside the Board's October 2015 decision to the extent that it denied the right knee claim, and remanded the matter for further adjudication consistent with the Joint Motion. In January 2016, the RO awarded an increased 70 percent rating for PTSD, effective January 2, 2016. As that increase did not represent a total grant of the benefit sought on appeal, the claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The Board then remanded the current issues for further development in November 2016. The Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). FINDINGS OF FACT 1. The Veteran's right knee musculoskeletal strain is not manifested by separately compensable limitation of flexion and limitation and extension, flexion limited to 30 degrees, extension limited to 20 degrees, instability, or cartilage impairment. 2. Prior to January 2, 2016, the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity. 3. Since January 2, 2016, the Veteran's PTSD has been productive of occupational and social impairment in the areas of work, judgment, thinking and mood, but has not been productive of total social and occupational impairment. 4. The most probative evidence is against a finding that the Veteran's neck disability had its onset in service or is otherwise related to service. 5. The Veteran's service-connected disabilities do not render him unemployable. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for service-connected right knee musculoligamentous strain have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3, 655, 4.1, 4.2, 4.10, 4.71a, Diagnostic Code 5260 (2017) 2. Prior to January 2, 2016, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.655, 4.130, Diagnostic Code 9411 (2017). 3. Since January 2, 2016, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.655, 4.130, Diagnostic Code 9411 (2017). 4. The criteria for establishing service connection for a neck disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.655 (2017). 5. The criteria for a TDIU have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 3.655, 4.15, 4.16, 4.18, 4.19 (2017) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Assist At the outset, the Board previously remanded the Veteran's claims for increased ratings, a TDIU, and service connection in November 2016 in order to afford the Veteran new examinations and to obtain potentially relevant outstanding records. The Veteran was informed in correspondence in November 2016 that a failure to report for his examination could serve as a basis for denial pursuant to 38 C.F.R. § 3.655(a),(b). The record shows that in December 2016, a C&P clerk called and spoke with the Veteran to schedule VA examinations to evaluate the current severity of his PTSD and right knee disabilities. However, the Veteran refused to schedule the examinations, stating that he "will refile when he has time to schedule appointments." Given the Veteran's examination refusals, the examination requests were canceled. Regarding the Veteran's neck/cervical spine service connection claim, a VA examination was scheduled for January 2017. The record shows that a notice letter was mailed to the Veteran's current address of record and two phone calls were made to the Veteran in December 2016, with messages left on an answering machine. Nevertheless, the Veteran failed to report for the January 2017 VA examination. He has not provided good cause, or any cause for that matter, for his failure to appear for that examination. In addition to refusing or failing to report for examinations, neither the Veteran nor his attorney has responded to requests for additional information or evidence concerning the Veteran's appeal, to specifically include a November 2016 letter sent pursuant to the Board's November 2016 remand requesting identification of additional evidence, authorization for the release of private records, as well as resubmission of a February 2016 statement and accompanying evidence in support of a TDIU claim. The Board observes that the Veteran also failed to report for multiple other appeal and non-appeal related VA examinations scheduled for January 2014, May 2014, and January 2016. He also did not appear for VA appointments, including a primary care appointment in August 2012, and for MRIs in November 2012 and December 2012, and did not respond to various phone calls to follow up on missed appointments. Indeed, though the Veteran's attorney asserted that the Veteran missed a January 2016 VA examination due to a claimed panic attack, the Board observes that the record supports a pattern of failing to appear for examinations and appointments without any, let alone "good," cause. The United States Court of Appeals for Veterans Claims has held that "[t]he duty to assist is not always a one-way street." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Veteran also has an obligation to assist in the adjudication of his claim. He must be prepared to meet his obligations by cooperating with VA efforts to provide an adequate medical examination and submitting to the Secretary all medical evidence supporting his claim. Olson v. Principi, 3 Vet. App. 480, 483 (1992). Individuals for whom examinations have been authorized and scheduled are required to report for them. 38 C.F.R. § 3.326. In view of the forgoing, the Board concludes that there is no duty to attempt to provide another examination or medical opinion with respect to the claims denied herein, and that an additional remand is not required to comply with the holding of Stegall v. West, 11 Vet. App. 268 (1998). See 38 C.F.R. § 20.704(d), (e); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Accordingly, the Board will proceed to a decision on the merits of the claims. II. Analysis As already discussed, the Veteran refused or did not report for the VA examinations that were scheduled in connection with the instant claims following the Board's November 2016 remand. Where entitlement to a benefit cannot be established or confirmed without a current VA examination and the Veteran does not report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655(b). Unfortunately, following review of that evidence, the Board finds that all claims must be denied. A. Increased Ratings Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities (Rating Schedule), which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claims when the disabilities may have been more severe than at other times during the course of the claims on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). A. Right Knee The Veteran seeks a rating in excess of 10 percent for his right knee disability, which is rated under Diagnostic Code 5260 for limitation of knee flexion. 38 C.F.R. § 4.71a. Following a review of the record, the Board finds that a higher rating is not warranted. Foremost, the record does not show limitation of right knee flexion to 30 degrees or limitation of right knee extension to 20 degrees to warrant a higher 20 percent rating under Diagnostic Codes 5260 and 5261, respectively. 38 C.F.R. § 4.71a. Instead, VA examination in September 2011 showed limitation of flexion to 120 degrees and full extension. There was no additional limitation of motion following repetitive use, though there was mild painful motion, mild weakness, and lack of endurance. VA treatment records also are silent for evidence of limitation of right knee flexion to 30 degrees or any limitation of right knee extension. Instead, in September 2012, full range of motion of the lower extremities was noted. Moreover, given evidence of full extension and noncompensable limitation of flexion, separate compensable ratings for limitation and extension are not warranted. Nor is a higher nor separate rating warranted for instability under Diagnostic Code 5257, as the September 2011 VA examiner found no ligamentous laxity or instability on examination. While the VA examiner did note some evidence of popping with complete extension of the right knee, the Veteran affirmatively denied locking and giving way, and the examiner did not otherwise indicate evidence of cartilage involvement or episodes of dislocation. Nor is any shown elsewhere in the record. Thus, a higher rating is not warranted under Diagnostic Code 5258. 38 C.F.R. § 4.71a. The Board recognizes the Veteran's reports of functional impairment, as well as his reports to the September 2011 VA examiner regarding use flare-ups that occur with heavy activity, twisting, and rotation that can last a week. Significantly, however, the Veteran reported that his right knee disability did not interfere with his work. Moreover, despite his claimed flare-ups, treatment records are silent for right knee complaints or otherwise show the Veteran to be active. For example, during September 2012 VA treatment, the Veteran denied chronic medical problems and, though he noted work-related ankle and elbow injuries, he did not report right knee problems. He also reported that prior to the onset of his right elbow and left ankle problems (shown by the record to have occurred between 3 and 7 months prior), he would run hills at a park two to three times per week and lift weights regularly. The Veteran reported that he was no longer able to engage in those activities due to his right elbow and left ankle pain; significantly, he, again, did not report right knee complaints. Also in September 2012, he reported gardening, hunting and fishing. Thus, despite his right knee disability, the Veteran was able to be active. In sum, the Board finds the objective evidence of record to be the most probative evidence of record and, here, the objective evidence does not support entitlement to a higher or separate rating for the Veteran's right knee musculoligamentous strain under any diagnostic code. B. PTSD The Veteran's PTSD is currently rated as 50 percent disabling for the period prior to January 2, 2016, and 70 percent thereafter, under 38 C.F.R. § 4.130, Diagnostic Code 9411. In order to warrant a rating higher 70 percent rating for the period prior to January 2, 2016, the evidence must show that the Veteran's PTSD is productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. In order to warrant a higher 100 percent rating for the period from January 2, 2016, the evidence must show that the Veteran's PTSD is productive of total social and occupational impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology, and the plain language of the regulation makes it clear that a Veteran's impairment must be "due to" those symptoms, and that a Veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Based on a review of the evidence of record, the Board finds that higher ratings are not warranted for the Veteran's PTSD at any time during the period on appeal. In reaching this decision, the Board has reviewed the evidence of record, to include VA treatment records, VA examination reports, lay statements from the Veteran, and considered all psychiatric symptomatology. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). For the period prior to January 2, 2016, the most probative evidence is a March 2013 VA examination during which the examiner expressly found the Veteran's PTSD to be productive of occupational and social impairment with reduced reliability and productivity. That determination was based on a review of the Veteran's treatment records, the Veteran's lay report of having held over 30 jobs and been fired due to verbal conflicts, and clinical evaluation of the Veteran, which revealed symptoms of anxiety, suspiciousness, chronic sleep impairment, disturbances in motivation and mood, irritability, and anger. The Veteran was also observed to have a mild degree of circumstantiality in thought processes. Nevertheless, the Veteran did not take medication for his PTSD and was assigned a GAF score of 58, supporting moderate symptoms. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition (DSM-IV)); see also Richard v. Brown, 9 Vet. App. 266 (1996). He reported support from family and friends, hobbies including playing the guitar, fishing, rebuilding, and caring for a new puppy. Additionally, on mental status examination he was observed to be appropriately dressed and groomed, socially appropriate, and to actively participate. He was also euthymic and had an affect that was appropriate to content of thought with some emotional lability. Judgment was not impaired, thought processes were logical, and thought content revealed no unusual materials such as hallucinations or delusions. Based on the foregoing, the VA examiner concluded that the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity. The Board finds that the March 2013 VA examiner's opinion as to the severity of the Veteran's PTSD is consistent with the ongoing VA treatment notes, while acknowledging that there is some evidence supportive of a higher rating. In this regard, those treatment records similarly document PTSD-related symptoms, including: suspiciousness; motivation problems; an inability to attend his kids' soccer games and avoidance of crowds due to anxiety; feelings of detachment and estrangement from others; sense of a foreshortened future; difficulty falling and staying asleep; anger and irritability problems; decreased interest in hobbies; guilty feelings; decreased energy; depressed mood; and decreased concentration. He also reported work-related stressors surrounding worker's compensation benefits, which resulted in conflict with a supervisor, and the Veteran was observed to be anxious in October 2012. However, ongoing VA treatment records also show that the Veteran denied depression in September 2012, and during ongoing treatment was routinely observed to be well-groomed or neatly dressed, to have good hygiene, good eye contact, and to be cooperative. Indeed, in September 2012 he was described as "pleasant in his interactions" and reported his mood as "good now." He was also observed during treatment to have an appropriate or variable affect, good insight, relevant and spontaneous speech, and logical and goal-directed thought processes. His ongoing GAF score was 55, indicative of symptoms of moderate severity. Of particular note, the Veteran was reported at times to be actively coping with different stressors. In September 2012, the Veteran reported coping through music, reading, gardening, and hunting/fishing. He also noted strengths in that he is indomitable, good in crises, had never failed, and he identified three friends as his key supports. During unrelated treatment the same month, he also reported that he played the guitar and, prior to physical injuries, he was running hills at a park 2-3 times per week and lifting weights regularly. At that time he was "[o]bserved to be well-groomed, pleasant, cooperative, attentive, and motivated." In November 2012, it was noted that the Veteran was actively coping with stressors through pursuit of legal means, avoidance of aggression, use of breathing, and planning around finances. He also reported progress in decreasing substance use and making efforts to get out to social activities. He further had some success with a recent writing project and was able to complete an interview, and he appeared happy about that. After November 2012, relevant treatment records include a July 2013 note indicating that the Veteran was not actively in treatment with the PTSD program, and a October 2015 note indicating that the Veteran's chart was closed due to lack of contact. Thus, for the period prior to January 2, 2016, the evidence shows that while the Veteran experienced impairment due to PTSD symptoms, such impairment was of no more than moderate severity, as he maintained relationships and friendships, actively participated in hobbies, was able to cope with stressors, and significantly, he did so without medication or even therapy throughout most the relevant period. Furthermore, the Veteran was described as pleasant and cooperative during treatment, and mental status examination was routinely normal with limited exception. Most probative, a March 2013 VA examiner expressly determined the Veteran's symptoms to be productive of impairment with reduced reliability and productivity, and that opinion is consistent with the evidence as a whole, and the currently-assigned 50 percent rating. Thus, a rating in excess of 50 percent for PTSD for the period prior to January 2, 2016, is not warranted. For the period since January 2, 2016, the Board similarly finds that a higher rating is not warranted. The relevant evidence for that period consists of a January 2016 VA examination report. That report shows that, following clinical evaluation of the Veteran and a review of the claims file, a VA examiner expressly found the Veteran's symptoms to be consistent with deficiencies in most areas, such as work, family relations, judgment, thinking, and/or mood, consistent with the currently-assigned 70 percent rating. The examiner did not find total social and occupational impairment. In this regard, the Veteran reported during the examination that his living situation remained the same (living with his long-term significant other and three children) and he was home taking care of his children. Additionally, mental status examination was essentially within normal limits with an "okay" mood and a broad affect. Thus, as total social impairment is not shown for the period since January 2, 2016, the Board finds that a higher 100 percent rating is not warranted. C. TDIU The Veteran asserts that he is entitled to a TDIU. Following a review of the record, the Board disagrees. Foremost, prior to January 2, 2016, the schedular criteria for a TDIU are not met, as the Veteran did not have a combined disability rating of at least 70 percent with a single disability rated at least 60 percent disabling. 38 C.F.R. § 4.16(a). Instead, he had a combined disability rating of 60 percent, with PTSD rated as 50 percent disabling and a right knee strain rated as 10 percent disabling. Moreover, the evidence during that period, discussed in more detail above, does not otherwise suggest that the Veteran's service-connected disabilities, alone or in combination, rendered him unemployable. In fact, the Veteran was working through November 2012. He further denied occupational interference due to his right knee disability during a September 2011 VA examination, and a March 2013 VA PTSD examiner did not otherwise suggest that the Veteran's PTSD rendered him unemployable. Thus, prior to January 2, 2016, a TDIU is denied. For the period since January 2, 2016, though the schedular criteria for a TDIU were met as of that date with the assignment of a 70 percent disability rating for PTSD, the Board similarly finds that a TDIU is not warranted. A January 2016 VA examiner did not find total occupational impairment due to PTSD, and the Board finds that the current record is otherwise insufficient to grant the claim, particularly given the Veteran's failure to attend an additional VA examination to evaluate the impact of his PTSD on his occupational functioning. 38 C.F.R. § 3.655(b). Indeed, regarding the TDIU claim and as it relates further to occupational impairment due to PTSD, the Board acknowledges the Veteran's reports of interference with or difficulty at work due to PTSD symptoms, including conflict with supervisors, as well as his report of having held over 30 jobs and been fired from jobs due to his PTSD. However, the ongoing VA treatment records show that the Veteran's initial difficulty at work started with physical injuries incurred at work when the Veteran was struck with a pipe by an intoxicated co-worker, with subsequent conflict arising from a dispute over worker's compensation benefits when the Veteran's supervisor's failed to file a claim for the Veteran. Such evidence does not support conflict due to the Veteran's PTSD symptoms. The treatment records also show that it was the Veteran who was going to leave his job, as reported in September 2012, but did not after he was advised by his attorney not to. In any event, while those treatment records do not necessarily contradict the Veteran's assertions regarding his employment history, neither do they support them. Regardless, in its prior remand, the Board requested that the Veteran submit evidence to support his assertions regarding occupational impairment, including having been fired from jobs due to PTSD symptoms, and the Veteran has failed to do so. And, as discussed, he failed to respond to November 2016 correspondence requesting additional evidence in support of his TDIU claim. Importantly, no VA examiner has found that the Veteran's PTSD or service-connected disabilities render him unemployable, and, as discussed, neither the September 2011 nor January 2016 VA examiner found total occupational impairment. In any event, regulations place responsibility for the ultimate TDIU determination on VA adjudicators, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (applicable). Here, despite evidence that the Veteran is not working, the totality of the evidence simply does not establish that the Veteran's service-connected PTSD alone or in combination with this right knee disability (which he reported did not interfere with his employment), rendered him unemployable during the period on appeal. In reaching the above conclusions concerning the increased ratings claims, to include entitlement to a TDIU, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). III. Service Connection The Veteran is seeking service connection for a cervical spine or neck disability, which he asserts was caused by carrying zodiac boats in service. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (2017). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). In this case, service treatment records, including a 1995 separation examination, are negative for neck complaints, findings, or diagnosis. A September 1993 STR also shows that examination of the Veteran's neck for stiffness was negative, and dental health questionnaires dated in May 1992, October 1993 and May 1995, document the Veteran's affirmative denial of painful joints. Post-service treatment notes are also negative for neck complaints or findings. They show that even when the Veteran's neck was examined on routine physical examination, no abnormality was found, such as in September 2012. At that time, the Veteran also denied chronic medical problems and, though he noted work-related ankle and elbow injuries, he did not mention any neck complaints. The Veteran was provided an examination in July 2013, pursuant to which a VA examiner assessed mechanical cervical strain and opined that it would be mere speculation to offer an opinion on a relationship between any current neck disability and service. While the Veteran reported that he had issues with his neck pulling boats in service, he had never been seen for any of his neck issues and the examiner noted that the Veteran had good range of motion, though he did have some mild discomfort with a few range of motion exercises. The examiner found that if the neck issues were due to the boat pulling in service, the Veteran would have been seen and his range of motion would be moderately decreased. The examiner also noted that the Veteran had done some construction/welding work over the years. Therefore, he concluded that any comments about the neck condition being specifically incurred in or caused by pulling boats in service would be resorting to speculation. The July 2013 VA examiner's opinion is the only competent opinion evidence of record related to the Veteran's neck disability, and the examiner declined to find that it is at least as likely as not that his right knee disability was caused by or is related to service. To the extent that the examiner indicated that an opinion would be speculative, the Board notes that there is no bar to a medical professional issuing an inconclusive opinion after obtaining and considering all relevant and available information. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010) ("[V]alid application of current medical knowledge could yield multiple possible etiologies with none more likely than not the cause of a veteran's disability, such that a physician could only speculate as to the cause of a claimant's disability or condition."). Furthermore, the rationale provided by the examiner - namely, the notations that more moderate decreased motion or medical visits for complaints would be expected if the Veteran's current neck disability was related to service - actually weighs against a finding of nexus. In any event, efforts to obtain an additional more conclusive opinion were stifled by the Veteran's failure to appear for an examination. In sum, there is also no competent medical opinion of record linking the Veteran's claimed neck disability to his period of service. The Board does not doubt that the Veteran sincerely believes that his neck complaints are related to service. However, the Veteran has not shown that he has specialized training sufficient to provide a competent opinion on that aspect of his claim. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Neck disabilities can have many causes, and forming a competent opinion regarding those causes requires medical testing and expertise. Thus, to the extent that the Veteran's filing of a claim constitutes his opinion that a nexus exists between his current neck disability and service, that opinion lacks probative value. Moreover, any suggestion by the Veteran to the VA examiner that he has experienced neck symptoms since service is belied by the service treatment records and post-service treatment records, which are negative for neck complaints. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006) ("[T]he Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc."). In short, the evidence of record does not reflect that the Veteran's neck disability manifested in service or for many years thereafter, and there is no probative evidence linking them to service. As a result, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim of entitlement to service connection for a neck disability must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER A rating in excess of 10 percent for a right knee musculoligamentous strain is denied. A rating in excess of 50 percent for PTSD for the period prior to January 2, 2016, is denied. A rating in excess of 70 percent for PTSD for the period from January 2, 2016, is denied. Service connection for a neck disability is denied. A TDIU is denied. ____________________________________________ S. C. KREMBS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs