Citation Nr: 1802720 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 11-25 338 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a right ankle disability, to include as secondary to the service-connected right and left knee disabilities. 3. Entitlement to service connection for a left ankle disability, to include as secondary to the service-connected right and left knee disabilities. 4. Entitlement to service connection for a sleep disorder, to include as secondary to the service-connected PTSD. 5. Entitlement to an initial rating higher than 10 percent for right knee osteoarthritis from May 3, 2007. 6. Entitlement to an initial rating higher than 10 percent for left knee osteoarthritis from May 3, 2007. 7. Entitlement to an initial rating higher than 10 percent for instability of the right knee. 8. Entitlement to an initial rating higher than 10 percent for instability of the left knee. 9. Entitlement to a total rating based on individual unemployability (TDIU) due to the service-connected disabilities. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. R. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty in the Army from June 1987 to October 1987, from March 2003 to June 2003, and from October 2005 to January 2007, including service in Iraq. The Veteran also had additional service in the Alabama National Guard. These matters are before the Board of Veterans' Appeals (Board) on appeal from May 2007 and December 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In August 2016, the Board remanded the appeal to the Agency of Original Jurisdiction (AOJ) for additional evidentiary development. In July 2017, the Veteran testified at a Board videoconference hearing before the undersigned. A transcript of the proceeding has been associated with the record. The Board notes that additional evidence has been submitted after the June 2017 and March 2017 supplemental statements of the case. However, the additional evidence is not relevant to the issues decided in this decision. The claim for a TDIU was reasonably raised in the context of the Veteran's increased rating claims. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009); see also VAOPGCPREC 6-96. At his May 2017 VA sleep examination, the Veteran indicated that he was not working due to his service-connected disabilities. The issues of entitlement to an initial rating higher than 10 percent for right and left knee osteoarthritis from May 3, 2007; entitlement to an initial rating higher than 10 percent for instability of the right and left knee; and, entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The PTSD has been productive of occupational and social impairment with reduced reliability and productivity; however, occupational and social impairment with deficiencies in most areas is not shown. 2. A right ankle disability is not currently manifest and did not manifest at any point during the appeal period. 3. A left ankle disability is not currently manifest and did not manifest at any point during the appeal period. 4. A sleep disorder is not currently manifest and did not manifest at any point during the appeal period. CONCLUSIONS OF LAW 1. The criteria for the assignment of an evaluation of 50 percent, but no higher, for PTSD have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). 2. A right ankle disability was not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.310 (2017). 3. A left ankle disability was not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.310 (2017). 4. A sleep disorder was not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist with regard to the issues decided below. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). As such, the case is ready to be decided on its merits. I. Increased Evaluation for PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2017). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2017). However, separate evaluations for separate and distinct symptomatology may be assigned where none of the symptomatology justifying an evaluation under one Diagnostic Code is duplicative of or overlapping with the symptomatology justifying an evaluation under another Diagnostic Code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Additionally, if two evaluations are potentially applicable, the higher evaluation is assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In an August 2011 rating decision, the Veteran was granted service connection for PTSD and assigned a 50 percent evaluation under Diagnostic Code 9411, effective April 30, 2009. The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and, difficulty in establishing and maintaining effective work and social relationships, warrants a 50 percent rating. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under these criteria, the next higher rating of 70 percent rating is warranted where the disorder is manifested by 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 that is 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 work-like setting); and, an inability to establish and maintain effective relationships. Id. The highest possible rating of 100 percent rating requires total occupational and social 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; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and, memory loss of names of close relatives, own occupation or own name. Id. The use of the term "such as" in the General Rating Formula for Mental Disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as mere examples of the type and degree of symptoms, or their effects, which would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to symptoms provided in that Diagnostic Code. Id. at 443. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V). Id. If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to what would be caused by the symptoms listed in a particular diagnostic code, the appropriate, equivalent rating will be assigned. Id. One factor for consideration is the Global Assessment Functioning (GAF) score, which is based on a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed., p. 32.)). GAF scores ranging from 61 to 70, reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Further, when evaluating the level of disability from a mental disorder, the rating agency shall consider the extent of social impairment, but shall not assign an evaluation based solely on the basis of social impairment. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only insofar as it affects earning capacity. 38 C.F.R. §§ 4.126, 4.130. In August 2011, the Veteran underwent a VA PTSD examination. The VA examiner diagnosed PTSD. At the time of the examination, the Veteran had been married for 19 years with 2 children. He indicated that he had been withdrawn from his family since his return from deployment in 2006. The Veteran reported no significant friendships or activities. He preferred to isolate and was unable to attend his son's sporting events because of the crowds. He was employed as a transportation supervisor. However, he had trouble getting along with co-workers and left work 6 to 7 times per month due to stress and irritability. His PTSD caused depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation. The VA examiner concluded that the Veteran's PTSD was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran was assigned a GAF score of 60. In January 2017, the Veteran underwent his most recent VA examination to determine the severity of his PTSD. The VA examiner commented that the results of objective psychological testing did not fully support the Veteran's symptoms. Since his last examination, the Veteran had respiratory complications, worsened arthritis, and increased problems at work. He still lived with his wife and younger son, but had few to no close friendships. He endorsed difficulty concentrating at work. The Veteran's PTSD symptoms were anxiety, chronic sleep impairment, flattened affect, and disturbances of motivation and mood. At the examination, the Veteran was neatly dressed and generally oriented. His affect was constricted and his mood was dysphoric. His speech was within the normal limits with regard to articulation, rate, fluency, and content. He presented with "significant dramatic flair, and he seemed to press the premise he was too tired or sluggish to function." The Veteran's level of alertness and engagement increased as the interview progressed. There was no evidence of circumstantial thinking, tangential thinking, flights of ideas, mania, or thought symptoms. He denied suicidal ideation or homicidal ideation. His short-term memory was grossly intact. His long-term memory was intact. The VA examiner concluded that the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity. The Veteran's VA treatment records reflect GAF scores between 55 and 69 for the appeal period. The Veteran testified that his PTSD made it difficult for him to be around a lot of people. He had conflicts at work and with his family. The Board finds that the weight of the evidence is against a 70 percent evaluation for the Veteran's PTSD. His PTSD is productive of occupational and social impairment with reduced reliability and productivity. He has demonstrated panic attacks more than once a week, impairment of short- and long-term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships - all symptoms associated with the 50 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. Although the August 2011 VA examiner found that the Veteran's PTSD caused suicidal ideation, he concluded that the Veteran's PTSD only caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Additionally, the Veteran denied suicidal ideation at his January 2017 VA examination. Throughout the appeal period, the Veteran's PTSD has been manifested by depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. These symptoms are associated with the assigned 50 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. Throughout the appeal period the Veteran has been assigned GAF scores ranging from 55 to 69, which indicates mild to moderate symptomatology consist with the Veteran's current 50 percent evaluation. Id. A 70 percent rating is warranted where the disability is manifested by 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 that is 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 work-like setting); and, an inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran has maintained relationships with members of his family. His thought processes and memory have remained intact. At his examinations, he was well-groomed and his speech was appropriate. Moreover, after considering the Veteran's associated symptomotalogy, the VA January 2017 examiner concluded that the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity. The evidence is against a disability rating in excess of 50 percent for his PTSD. Id. The Board concludes that the medical findings on examination are of greater probative value than the Veteran's allegations regarding the severity of his PTSD, as the conclusions of the VA examiners were based upon the Veteran's lay statements, reviews of the record, clinical findings, and their medical expertise. An evaluation in excess of 50 percent disability for the Veteran's PTSD is denied. 38 C.F.R. § 4.130, Diagnostic Code 9411. II. Service Connection To establish direct service connection, the record must contain: (1) medical evidence of a current disorder; (2) medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease; and, (3) medical evidence of a nexus between the current disorder and the in-service disease or injury. In other words, entitlement to service connection for a particular disorder requires evidence of the existence of a current disorder and evidence that the disorder resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C. § 1113(b) (2012); 38 C.F.R. § 3.303(d). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); see 38 C.F.R. § 3.102 (2017). If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, the regulations provide that service connection is warranted for a disorder that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected disability, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected disability, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary disorder, the secondary disorder shall be considered a part of the original disability. Id. The Board notes that 38 C.F.R. § 3.310 was amended, effective October 10, 2006. Under the revised § 3.310(b) (the existing provision at 38 C.F.R. § 3.310(b) was moved to sub-section (c)), any increase in severity of a non-service-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service-connected. In reaching this determination as to aggravation of a non-service-connected disorder, consideration is required as to what the competent evidence establishes as the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected disability), in comparison to the medical evidence establishing the current level of severity of the non-service-connected disease or injury. These findings as to baseline and current levels of severity are to be based upon application of the corresponding criteria under the Schedule for Rating Disabilities (38 C.F.R. part 4) for evaluating that particular non-service-connected disorder. See 71 Fed. Reg. 52,744-47 (Sept. 7, 2006). A. Ankles The Veteran testified that his ankles buckle and give way when he walks. He asserted that he has bilateral ankle disabilities that were either caused or aggravated beyond their natural progression by his service-connected bilateral knee disabilities. In February 2017, the Veteran was afforded a VA examination to determine the nature and etiology of his claimed ankle disabilities. At the examination, the Veteran reported that problems with his ankles began in 2007. He was involved in an attack in Iraq and fell on cement. He hit his knees and injured his ankles. The Veteran reported no current treatment for his ankles. Despite the Veteran's complaints, ranges of motion studies were normal bilaterally and there was no pain noted on examination. The Veteran was able to complete three repetitions, and there was no additional loss of function or range of motion after three repetitions bilaterally. Strength testing and stability testing were also normal. The VA examiner concluded that the Veteran did not have any current ankle disabilities. Similarly, the Veteran's VA and private treatment records are silent with respect to any complaints of ankle pain or treatment for an ankle disability. The Board has considered the Veteran's statements regarding his claimed ankle disabilities. The Veteran is competent to provide evidence of that which he experiences, including his ankle symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In addition, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or, (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). While the Veteran is competent to report symptomatology related to his ankles, the Board finds that his statements regarding continuing ankle symptoms are not credible. The Veteran's treatment records contain numerous references for treatment related to his knee disabilities. However, the Veteran did not report any complaints related to his ankles. The Board finds that the Veteran's contemporaneous statements to medical providers are more probative regarding a current ankle disability than his current allegations of current ankle disabilities. When the Veteran had a chance to report an ankle disability or ankle pain, he was silent. In this instance, the Board concludes that the most probative evidence establishes that the Veteran does not currently have a current ankle disability or residuals thereof. In making this determination, the Board has placed significant probative weight on the opinion proffered by the VA examiner who is a trained medical professional who is competent to render medical opinions. As a layperson, the Veteran does not have the competency to render medical opinions regarding the presence of any chronic ankle disability associated with his subjective complaints. The existence of a current disability is the cornerstone of a claim for VA disability benefits. Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). In the absence of current disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Likewise, 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. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). In this case, there is no disability that resulted from a disease or injury. Under the circumstances, the Veteran has not met the regulatory requirements to establish service connection under any theory of entitlement and service connection must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. Here, however, as the preponderance of the evidence is against the claims, that doctrine is not applicable. The claims are denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). B. Sleep Disorder The Veteran testified that he had difficulty sleeping and was only able to sleep between 3 and 4 hours per night. He associated his difficulty sleeping with his service-connected PTSD. In May 2017, the Veteran was afforded a VA sleep apnea examination to determine the nature and etiology of his claimed sleep disorder. The Veteran endorsed night sweats, talking in his sleep, restless sleep, nightmares, and reliving his PTSD stressors. He indicated that his symptoms started in 2007 with his last deployment. His symptoms caused difficulty staying asleep or getting to sleep. He was on medication for his condition. The Veteran did not require the use of a continuous positive airway pressure machine. There were no findings, signs, or symptoms attributable to sleep apnea. The VA examiner acknowledged that there were complaints of sleep problems throughout the medical record. However, there were no separate sleep-wake disorders. The Veteran's sleep problems varied and were responsive to medication. The VA examiner concluded that there was a lack of medical evidence to support a separate sleep-wake disorder. The Veteran's treatment records include complaints of sleep problems. However, there are no separate sleep disorder diagnoses of record. The Board has considered the Veteran's statements regarding his claimed disorder. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno, 6 Vet. App. at 469. In addition, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or, (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d at 1377. The Veteran's statements regarding difficulty sleeping are both competent and credible. However, they are probatively outweighed by the VA examination report. The VA examination finding was based upon consideration of the medical evidence of the record, an examination, consideration of the Veteran's lay statements, and the VA examiner's medical expertise. In this instance, the Board concludes that the most probative evidence establishes that the Veteran does not currently have a separate sleep disorder. Rather, the evidence of record supports the finding that the Veteran's difficulty sleeping is a symptom related to his service-connected PTSD and has been considered in the rating assigned for PTSD. The existence of a current disability is the cornerstone of a claim for VA disability benefits. Degmetich, 104 F.3d at 1328. In the absence of current disability, there can be no valid claim. Brammer, 3 Vet. App. at 225. Likewise, 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. Sanchez-Benitez, 259 F.3d at 1356. In this case, there is no disability that resulted from a disease or injury. Under the circumstances, the Veteran has not met the regulatory requirements to establish service connection under any theory of entitlement and service connection must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. Here, however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. The claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. ORDER Entitlement to an evaluation in excess of 50 percent for PTSD is denied. Entitlement to service connection for a right ankle disability, to include as secondary to the service-connected right and left knee disabilities, is denied. Entitlement to service connection for a left ankle disability, to include as secondary to the service-connected right and left knee disabilities, is denied. Entitlement to service connection for a sleep disorder, to include as secondary to the PTSD, is denied. REMAND The Veteran most recently was afforded a VA examination to determine the current nature and severity of his service-connected bilateral knee disabilities in December 2017. The VA examiner did not provide measurements in degrees for the ranges of motion of the Veteran's bilateral knees in active motion, passive motion, weight-bearing, and non-weight-bearing. All of these measurements provided in degrees are necessary for the examination to be considered adequate under Correia v. McDonald, 28 Vet. App. 158 (2016). Accordingly, the Board finds that an updated VA examination is needed before the Veteran's claims for increased evaluations for his bilateral knee disabilities can be adjudicated. The Board is aware that the December 2017 examination report notes that range of motion testing was not completed due to the "Veteran's fear of pain with any movement" of his knee and ankle joints. However, it is unclear whether there is the nature of the Veteran's knee disabilities prohibits the required testing. The Veteran is reminded that while VA has a statutory duty to assist the Veteran in developing evidence pertinent to a claim, he also has a duty to assist and cooperate with VA in developing evidence; the duty to assist is not a one-way street and his cooperation is required for proper development of his claim. See Hayes v. Brown, 5 Vet. App. 60, 68 (1993). If the Veteran is unable to complete range of motion testing, the examiner must indicate whether such is due to physical impairment or functional limitation of the knee or due to the Veteran's unwillingness to cooperate with the examination. Evidence obtained as a result of the Board's remand will provide more information regarding the Veteran's disability picture. Additionally, the AOJ has scheduled the Veteran for a TDIU examination. Based upon the forgoing, the Board will defer adjudication of the Veteran's claim for a TDIU. Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for a VA examination by an examiner with the appropriate expertise to ascertain the severity of the service-connected knee disabilities, to include retrospectively. The examiner must review the claims file and should note that review in the report. The examination report must include ranges of motion of the bilateral knees in active motion, passive motion, weight-bearing, and nonweight-bearing, with notations as to the degree of motion at which the Veteran experiences pain. The extent of any weakened movement, excess fatigability, and incoordination on use should also be described by the examiner. The examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. The VA examiner must also provide, to the extent possible, a retrospective medical opinion addressing the ranges of motion and additional functional impairment of the bilateral knees since 2007, based on the findings that are otherwise available. The examiner should provide a rationale for any opinion expressed and reconcile that opinion with all pertinent evidence of record, including all relevant VA medical records and any lay evidence suggesting that Veteran's service-connected bilateral knee disabilities are worse than shown on some prior examinations. The examiner should provide, to the extent possible, a retrospective medical opinion with respect to the severity of the Veteran's service-connected knee disabilities since 2007, based on the findings that are otherwise available. The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups of the bilateral knees. The examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. The VA examiner must also provide, to the extent possible, a retrospective medical opinion addressing the functional impairment of the bilateral knees since 2007, based on the findings that are otherwise available. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. If the Veteran is unable or unwilling to complete range of motion testing, the examiner must indicate whether such is due to physical impairment or functional limitation of the knees or due to the Veteran's unwillingness to cooperate with the examination. 2. After the above action has been completed, readjudicate the Veteran's claims. If any of the benefits sought remain denied, issue the Veteran and his representative a supplemental statement of the case. Afford him the appropriate period of time within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs