Citation Nr: 1805925 Decision Date: 01/30/18 Archive Date: 02/07/18 DOCKET NO. 13-13 440 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for a right hand disability. 2. Entitlement to service connection for a left hand disability. 3. Entitlement to increases in the (10 percent prior to July 23, 2014, and 30 percent from September 1, 2015) ratings assigned for a left knee disability, now post total knee replacement (TKR). 4. Entitlement to extraschedular ratings under 38 C.F.R. § 3.321(b) for right knee orthopedic disability and right knee scarring. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The appellant is a Veteran who served on active duty in the U.S. Coast Guard from June 1971 to June 1975 and in the Army from December 1990 to January 1992. He also had non-Federalized Army National Guard service from July 1982 to February 1988, September 1989 to December 1990, and January 1992 to September 1995; Army Reserve service from February 1995 to June 1999; and non-Federalized Army National Guard service thereafter until March 2012. This case comes to the Board of Veterans' Appeals (Board) on appeal of various rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. Specifically, the issue of extraschedular ratings under 38 C.F.R. § 3.321(b) arises from rating decisions in January 2009 (relating to right knee orthopedic disability) and October 2012 (relating to right knee scar); the issue of service connection for a right hand disability arises from a May 2011 rating decision; and the issues of service connection for a left hand disability, and seeking higher ratings for a left knee disability, and a TDIU rating arise from October 2012 rating decisions. In March 2014, a videoconference hearing was held before the undersigned; a transcript is associated with the record. In March 2015, the Board denied various other claims, to include higher ratings for a right knee disability and a higher rating for posttraumatic stress disorder (PTSD) prior to March 25, 2010, and remanded issues seeking service connection for bilateral hand disabilities, higher ratings for a left knee disability and bilateral hearing loss, and a TDIU rating. The Veteran appealed the Board's decision in part to the United States Court of Appeals for Veterans Claims (CAVC). In February 2016, the parties - the Veteran and the legal representative of the VA, the Office of the General Counsel - filed a Joint Motion for Partial Remand (Joint Motion) to vacate the Board's decision to the extent that it denied an effective date earlier than March 25, 2010 for the award of a 50 percent rating for PTSD and an extraschedular rating under 38 C.F.R. § 3.321(b) for right knee orthopedic disability and right knee scarring, and to remand the case to the Board. CAVC granted the Joint Motion in February 2016. In October 2016, the Board denied a compensable rating for bilateral hearing loss and a rating higher than 50 percent for PTSD prior to March 25, 2010, and such issues are no longer before the Board, and remanded the case to the RO for additional development on the five remaining issues listed on the first page of . A February 2017 Decision Review Officer decision, in pertinent part, granted service connection for peripheral neuropathy of the right lower extremity as secondary to the service-connected right knee surgical scar, rated 10 percent, effective March 20, 2014 (the date of informal claim during Board hearing); granted service connection for peripheral neuropathy of the left lower extremity as secondary to the service-connected left knee surgical scar, rated 10 percent rating, effective November 15, 2016 (the date of VA examination reporting the nature, etiology, and severity of the disability); and granted service connection for a left knee surgical scar, rated 0 percent, effective September 1, 2015 (the day following the end of a convalescence period). The Veteran continued his appeals seeking a higher rating for the left knee disability and extraschedular ratings for the right knee disability. The issues seeking ratings for a left knee disability higher than 10 percent prior to July 23, 2014, and higher than 30 percent from September 1, 2015, and extraschedular ratings under 38 C.F.R. § 3.321(b) for right knee orthopedic disability and right knee scarring are being REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if action is required. FINDINGS OF FACT 1. A chronic right hand disability is not shown to have had its onset during service; arthritis of the right hand was not manifested to a compensable degree within one year following the Veteran's separation from his first period of active duty service in June 1975 or his second period of active duty service in January 1992; and his current right hand disability is not shown to be related to an injury, disease, or event in service. 2. A chronic left hand disability is not shown to have had its onset during service; arthritis of the left hand was not manifested to a compensable degree within one year following the Veteran's separation from his first period of active duty service in June 1975 or his second period of active duty service in January 1992; and his current left hand disability is not shown to be related to an injury, disease, or event in service. 3. Beginning February 1, 2012, the Veteran's service-connected disabilities were: status post right TKR, [rated] 60 percent; PTSD with major depressive disorder, 50 percent; bronchial asthma, 30 percent; muscle tension headaches associated with PTSD, 10 percent; tinnitus, 10 percent; degenerative joint disease of the left knee, 10 percent; bilateral hearing loss (0 percent, from March 2012); surgical scar of the right knee, 10 percent (and 0 percent from September 25, 2012); the combined rating was 90 percent; and such disabilities are reasonably shown to have been of such nature and severity as to prevent him from maintaining substantially gainful employment consistent with his education, work experience, and training. CONCLUSIONS OF LAW 1. Service connection for a right hand disability is not warranted. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 2. Service connection for a left hand disability is not warranted. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2017). 3. The criteria for a TDIU are met; a TDIU rating is warranted from February 1, 2012. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16, 4.18, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. As this decision grants TDIU, discussion of the impact of the VCAA on that matter is not necessary. Regarding the claims of service connection for right and left hand disabilities, the RO provided content-complying, pre-adjudication VCAA notice by letters dated in February 2011 and September 2012 . The Veteran was afforded a hearing before the undersigned in March 2014. CAVC has held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who conducts the hearing has the duty to fully explain the issues and to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, at the hearing the undersigned explained the issues, focused on the elements necessary to substantiate the claims (e.g., a current diagnosis of a hand disability, and evidence that the current disability is related to service), and sought to identify any further development that was required to substantiate the claims. It is not alleged that the Veteran has been prejudiced by the conduct of the hearing. The RO has obtained the Veteran's available service treatment records (STRs) and relevant postservice records, to include VA medical records. In August 2015 and April 2017 letters to the Veteran the RO solicited specific information regarding when he sustained hand injuries in service, the nature of the injury, and the unit to which he was then assigned; he did not respond with the information sought. The RO also acknowledged that STRs for the Veteran's period of service from December 1990 to January 1992 are missing; a VA administrative decision in September 1997 had determined (in relation to a different claim) that such STRs were unavailable. An October 2012 RO letter requested the Veteran to submit copies of any STRs from this period of service in his possession, and a July 2013 statement of the case again notified the Veteran of the missing STRs. He has not identified any additional pertinent evidence that is available. VA provided the Veteran examinations to ascertain the nature and etiology of his bilateral hand disabilities in February 2013 and November 2016, . The examiners reviewed the significant facts in the case and provided rationale supporting the conclusions reached. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board concludes that no further assistance to the Veteran in developing facts pertinent to these claims is required; VA's duty to assist is met. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Service Connection for Right and Left Hand Disabilities Legal Criteria Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially 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). The term "active military, naval, or air service" includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101(21), (24); see also 38 C.F.R. § 3.6. Diseases or injuries incurred or aggravated while performing ACDUTRA are eligible for service connection. 38 U.S.C. §§ 101(24), 106, 1110, 1131. When a claim is based on a period of Reserve or National Guard service, it must be shown that the individual concerned became disabled (or died) as a result of a disease or injury incurred or aggravated in the line of duty (on Reserve ACDUTRA/INACDUTRA or during federalized National Guard service). Otherwise, the period would not qualify as "active military, naval, or air service" and the claimant would not achieve "veteran status" for purposes of that claim. See 38 U.S.C. § 101(2)-(24). A member of the National Guard serves in the federal military only when formally called into the military service of the United States. At all other times, a member of the National Guard serves solely as a member of the State militia under the command of a state governor. To have basic eligibility as a veteran based on a period of duty as a member of a state Army National Guard, a National Guardsman must have been ordered into Federal service under 38 U.S.C. §§ 316, 502, 503, 504, 505. 38 C.F.R. § 3.6(c), (d). Allen and Key v. Nicholson, 21 Vet. App. 54, 57 (2007). Hence, for the Veteran's National Guard service, only periods of Federalized service are qualifying service for the purpose of VA compensation benefits. Certain chronic diseases (including arthritis), may be service connected on a presumptive basis if manifested to a compensable degree within a specified period of time following discharge from service (one year for arthritis). 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. To substantiate a claim of service connection, there must be evidence of a current claimed disability; evidence of incurrence or aggravation of a disease or injury in service; and evidence of a nexus between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1153, 1166-1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Factual Background and Analysis The Board has reviewed all of the evidence in the record. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence of record. See Gonzales v. West, 218 F. 3d 1378, 1380-81 (Fed. Cir. 2009). Hence, the Board will summarize the relevant evidence as deemed appropriate, and the Board's analysis will focus specifically on what the evidence shows with respect to the claims. The Veteran claims arthritis in his hands was incurred in service. Service department records indicate that he served on active duty in the U.S. Coast Guard from June 1971 to June 1975 and in the Army from December 1990 to January 1992. He also had other military service, as follows: Army National Guard from July 1982 to February 1988, September 1989 to December 1990, and January 1992 to September 1995; Army Reserve service from February 1995 to June 1999; and Army National Guard service thereafter until March 2012. Notably, military personnel records do not show that his National Guard service was "federalized;" hence, any periods of ACDUTRA or INACDUTRA during those periods are non-qualifying for VA compensation purposes. The only periods of federalized (and thus qualifying for VA compensation benefits) service were from June 1971 to June 1975 and from December 1990 to January 1992, as well as ACDUTRA and INACDUTRA in the Army Reserves from February 1995 to June 1999. The Veteran's service treatment records (STRs) do not document any complaints, findings, treatment, or diagnoses relating to the hands, with two exceptions as to the right hand. In August 1971, the Veteran sustained a right hand injury involving a laceration of the 2nd and 3rd digits. On May 1975 separation physical examination the Veteran's upper extremities were normal on clinical evaluation. On a July 1982 enlistment physical examination for the National Guard, the Veteran's upper extremities were evaluated as normal; a right anterior wrist scar was noted as non-disqualifying. He denied a history of swollen or painful joints at that time. On a periodic National Guard physical examination in February 1987, the upper extremities were evaluated as normal. There is also documentation that in May 1993, he was seen after he injured an index finger while pounding a ground stake with a sledgehammer. He sustained a laceration of the right index finger, described as a superficial injury. A notation in a May 1993 statement of medical examination and duty status indicates that the Veteran was on inactive duty for training at the time (a report of accident notes that it occurred during "Armory Drill" training), but this particular injury occurred during a period of the Veteran's National Guard service that is not shown to be federalized service. A February 1995 Report of Medical History indicates that the Veteran reported a history of swollen or painful joints, which the examiner noted was in reference to a right knee injury. On a September 1996 physical examination for Reserves, the Veteran's upper extremities were evaluated as normal, and he denied a history of swollen or painful joints. In August 1994, the Veteran filed an application for VA compensation or pension for disability related to his service in the Persian Gulf, and his claim was for service connection for bronchitis (there was no reference to a hand disability). A November 1994 VA general medical examination report does not note any hand complaints or disabilities. In November 1997, the Veteran filed a claim of service connection for PTSD (there was no reference to a hand disability). VA medical records indicate that in a list of outpatient encounters, the Veteran was seen on January 6, 1999 for an unspecified disorder of the hand joint (notes of that visit, however, do not reflect a hand complaint or problem). A January 2000 emergency room record notes that the Veteran was seen with a request to refill pain medications for a right hand fracture sustained on January 6, 2000. A subsequent January 2000 X-ray of the right hand showed a healing fracture of the right 4th metacarpal. In June 2006, the Veteran complained of some numbness in his right hand fingertips at night and at work; the assessment was probable carpal tunnel on the right. In April 2007, the Veteran reported that he had injured his left hand at work the prior week (i.e., a crush injury with multiple stitches in the left 3rd and 4th digits, involving proximal interphalangeal (PIP) joints of both fingers). A November 2007 mental health record references a "[s]eriously injured hand." In February 2010, the Veteran reported bilateral hand pain that began six years earlier. He stated that he noticed pain while doing closed hand pushups in the Reserves. The assessment was left-sided hand pain with carpal metacarpal (CMC) osteoarthritis. VA records show that on a February 2012 rheumatology consult, the Veteran related that he noticed pain in both hands and that in "reserves" he noticed pain with closed hand pushups. He reported the onset of left hand symptoms about six years previously. The examiner reviewed with the Veteran the results of X-rays of the hands taken in November 2011, which showed mild 1st CMC osteoarthritis in the right hand and moderate osteoarthritis of the 3rd and 5th PIP and mild similar changes at the 1st CMC in the left hand. On a February 2013 VA fee-basis examinations, the Veteran reported that he first developed pain while performing physical training, and that it has worsened. He stated that arthritis of the thumb and carpal tunnel syndrome were diagnosed by VA in 1998. The diagnoses were degenerative joint disease of the right hand and wrist and bilateral carpal tunnel syndrome. (No electromyography (EMG) studies were completed to confirm carpal tunnel syndrome, and no opinion regarding etiology of the disabilities was provided.) VA records also show that in February 2013 there was a diagnosis of left hand moderate osteoarthritis of the 3rd and 5th PIP and mild similar changes of the 1st CMD. In May 2013, the Veteran had a diagnosis of bilateral basilar thumb arthritis. His past surgical history was notable for a right 4th metacarpal fracture open reduction and internal fixation (ORIF) in 2000. A March 2014 arthritis consult noted that the Veteran had left hand 1st CMC joint pain and he was referred to hand surgery. In December 2015, he underwent surgical treatment of the left thumb osteoarthritis (specifically, left thumb CMC arthroplasty with trapeziectomy and flexor carpi radialis tendon transfer and interposition). At a Board hearing in March 2014, the Veteran testified that he believed his hand disabilities were traceable back to his duties in service, which included wear and tear from "[e]quipment that I had to put up, camouflage netting to loading equipment on a - - on a rig. It's a variety of things. Putting up 292 antennas... you got to grip things..." He stated that he started noticing problems with his left hand around 1993 or 1994, and that he had some numbness and tingling in his hands. On November 2016 VA contract examination, the Veteran reported that the onset of his hand disability was in the early 1980s with slow development and progression of movement related to the 1st CMC pain. He recalled no specific injury, event, or illness. He also related that he had reduced range of motion of the left long and ring fingers due to a nonservice-connected work-related accident some years ago [in 2007]. He noticed swelling about the 1st CMCs bilaterally in the mid-2000s. He then received local steroid injections on both hands (about 15 on left and 6 on right), with temporary relief, followed by tendon transplantation surgery in 2015. He continued to complain of pain in the right 1st MCP joint, and some pain and limitation of motion in the left 1st CMC. The diagnosis was bilateral degenerative arthritis (finger and thumb) of the hands, status post left thumb CMC surgical procedure, and left long and ring finger crush injury. The examiner stated that there was no evidence of carpal tunnel syndrome (he noted the record did not reveal any EMG testing and that median nerve provocation tests were negative). As to the diagnoses, the examiner stated that it was not at least as likely as not that they were related to the Veteran's military service. He did not find any record of an injury in service that was likely to result in a multi-site CMC and interphalangeal (IP) osteoarthritis that was found. He discussed the May 1993 right index finger injury, finding that it was small, superficial, and did not necessitate X-rays; he stated it was unlikely to lead to generalized hand and finger osteoarthritis. As for the documented August 1971 right hand laceration, he stated that it was not the type of injury that would be expected to result in osteoarthritis at multiple locations about both hands. He did not find documentation of any other incidents that would likely result in multi-site hand osteoarthritis. He acknowledged the Veteran's claims about his military duties causing wear and tear to the hand, and concluded that such activities described by the Veteran as stringing telephone wire, using a radio teletype, using wire cutters, typing, and manipulating camouflage netting were not unusual and were not beyond the scope of everyday hand activities. He found they were unlikely to cause or aggravate multi-site hand osteoarthritis. He asserted that the pattern of arthritis seen in the Veteran was a common pattern that was usually attributed to generalized aging and that did not implicate a specific etiologic event or trauma. The left hand surgical procedure was stated to have arisen from the hand osteoarthritis and therefore not likely related to service. As to the left long and ring finger crush injury, he stated that this event occurred after active duty. It is not in dispute that the Veteran currently has right and left hand disabilities, to include arthritis in both hands, which have been diagnosed and treated. However, they are not shown to have been manifested in service. With two exceptions relative to the right hand, the Veteran's STRs contain no notations pertaining to such disabilities. Although service records show that the Veteran was treated for lacerations on his 2nd and 3rd digits of the right hand in August 1971, as well as a right index finger laceration in May 1993 (which occurred during non-federalized National Guard service), there was no complaint or finding relating to a chronic hand disability in service. On discharge from service in June 1975, clinical evaluation was normal; no hand problems (to include arthritis) were noted or reported. There is no evidence of a right or left hand problem until the trauma to his right index finger in May 1993 (a period that does not qualify for VA compensation benefits), after which there was no further indication of a hand or finger complaint or disability for many years. Thus, on the basis of the STRs alone, the claimed right and left hand disabilities were not affirmatively shown to have been present in service. Accordingly, service connection under 38 U.S.C. §§ 1110, 1131, and 38 C.F.R. § 3.303(a) (affirmatively showing inception in service) is not established. The Veteran is competent to describe certain symptom manifestations of the claimed disability, such as pain in his hands, even though the symptoms were not recorded during service. Layno v. Brown, 6 Vet. App. 465, 470-71 (1994) (Lay testimony is competent evidence insofar as it relates to symptoms of an injury or illness.). As the STRs lack the documentation of the combination of manifestations sufficient to identify the disability and sufficient observation to establish chronicity during service, and as chronicity in service is not adequately supported by the STRs, then there must be a showing of continuity of symptoms after service to support the claims. 38 C.F.R. § 3.303(b). However, the evidence here does not establish continuity of symptoms after service to support the Veteran's bilateral hand claims. Right or left hand disabilities were not found on separation from service in June 1975 (or in January 1992). There was no indication on May 1975 separation physical examination of any residuals of the injury to two right hand fingers that the Veteran sustained in 1971. Moreover, there are no separation physical examination reports from the Veteran's second period of service that ended in January 1992 to show any hand complaints or problems. (The documented second injury to the right hand in 1993 occurred during a period of non-federalized National Guard service.) The Veteran has asserted that he sustained injury to his hands during service, to which he maintains has led to the development of arthritis in both hands. He has also testified that his military duties caused wear and tear on his hands, which led to arthritis, and that he started noticing problems with his hands in 1993 or 1994. More recently, he reported to a VA examiner that the onset of his hand disability was in the early 1980s. Thus, in his statements and testimony, the Veteran appears to allege both that he has had ongoing hand symptoms ever since a year or two after his service discharge in January 1992, and that he has had ongoing symptoms ever since the 1980s (i.e., before he entered active service for the second time in December 1990). Such statements lack credibility in light of the contemporaneous record before, during, and after service. The assertions of a right or left hand disability existing since service, while competent, lack credibility because they are self-serving and inconsistent with contemporaneous recorded clinical and other data. For example, if the Veteran had a hand disability that started in service and continued thereafter, he presumably would have reported it at his separation physical examination in 1975, or given his assertions about symptom onset in the 1980s, on National Guard physical examinations in 1982 and 1987 . A Reserve physical examination in 1996 also did not note any hand complaint or disability. Reasonably, it would be expected that if he had continuous right and/or left hand problems since service, he would have sought treatment for them earlier. Additionally, it is noteworthy that when he filed claims for VA compensation benefits in 1994 and 1997, he did not mention any hand disability, but claimed compensation for disabilities involving the lungs and PTSD. The omission of hand disabilities at the time suggests there were none. There are no medical records that document any chronic hand problems until after the Veteran sustained a fracture of the right hand in 2000 (a 1999 reference to a potential unspecified hand joint was not confirmed at that time). The Veteran has not offered any explanation for the silence regarding any hand problems on treatment records or VA applications. In short, based on the lay statements/testimony and medical records, it is the Board's judgment that continuity of symptomatology to support the claims of service connection is not shown. The preponderance of the evidence is against the claims of service connection for right and left hand disabilities based on continuity of symptoms under 38 C.F.R. § 3.303(b). Further, the initial documentation of arthritis of the hands in the medical records in the 2000s (some records indicate the mid-2000s, one left hand assessment shows 2010, and X-rays definitively establish osteoarthritis in 2011) - at least 10 years after service separation - is well beyond the one year presumptive period for arthritis as a chronic disease under 38 U.S.C. § 1112 and 38 C.F.R. §§ 3.307 and 3.309. Hence, service connection for right and left hand disabilities on a chronic disease presumptive basis is not warranted. The Board turns to whether service connection for right and/or left hand disabilities may be granted on the basis that such disabilities, while first diagnosed after service, are shown to have been incurred in service considering all the evidence, including that pertinent to service under 38 C.F.R. § 3.303(d). It is not in dispute that the Veteran currently has disabilities of both hands, including bilateral hand arthritis. Although diagnosed in the February 2013 VA examination, carpal tunnel syndrome was not found in the November 2016 VA examination - the examiner reviewed the claims file and stated that there was no EMG testing to confirm it and that median nerve provocation tests were negative. (In any case, carpal tunnel syndrome is a disability that is related to median nerve injury in the wrist, which has symptom manifestations in the hand; the Veteran's claims appear to be localized to hand injury as manifested by arthritic pain in the hand.) A November 2016 VA opinion which addresses whether the disabilities may be related to service is unfavorable to the Veteran's claims. The examiner, who conducted examination of the Veteran and reviewed the claims file, found that it was not at least as likely as not - a less than 50 percent probability - that the Veteran's currently diagnosed bilateral hand disabilities including arthritis are related to (caused or aggravated by) an injury, event, or illness in service . He considered the Veteran's particular assertions regarding military duties causing wear and tear to the hands, and concluded that the current pattern of the osteoarthritis in the hands was more indicative of aging than a specific etiologic event or trauma. The Veteran has provided no favorable opinions in support of his claims. Therefore, the Board concludes that the preponderance of the medical evidence is against the Veteran's claims of service connection for right and left hand disabilities. The Veteran's own statements can be used only to provide a factual basis upon which a determination could be made that a particular injury occurred in service, but not to provide a diagnosis or to linking a current disability to a disease or injury in service. Although he is competent to describe such symptoms as hand pain, see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of personal knowledge), arthritis of the hands is not a condition found under caselaw to be capable of lay observation. The diagnosis of arthritis, which is confirmed by diagnostic studies such as X-rays (here done in 2011), and the etiology of such pathology are complex medical questions incapable of resolution by lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). It is not argued or shown that the Veteran is qualified through specialized education, training, or experience to offer a medical opinion regarding the etiology of the hand disabilities at issue. To the extent his own statements and testimony are offered as proof of an etiological relationship between the current bilateral hand disabilities and his active duty service, they are not competent evidence and may not be considered probative evidence supporting the claims. In view of the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claims of service connection for right and left hand disabilities, and that the benefit-of-the-doubt rule does not apply. The appeal in this matter must be denied. 38 U.S.C. § 5107(b). TDIU A TDIU rating may be assigned where the schedular rating is less than total, when it is found that the veteran is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability rated 60 percent or more, or as a result of two or more disabilities, provided at least one is rated 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or higher. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Disabilities resulting from common etiology or affecting both upper and/or lower extremities (including the bilateral factor), are treated as one collective disability for the purpose of determining whether these schedular rating requirements are met. The Veteran's service-connected disability ratings have fluctuated ever since January 1992, as service connection for additional disabilities has been established and as he has undergone various surgical interventions for which temporary total convalescence ratings were awarded (as from December 8, 2010 to February 1, 2012 for right TKR, and from July 23, 2014 to September 1, 2015 for left TKR). A review of the record found that the Veteran has met the schedular rating requirement for a TDIU rating under 38 C.F.R. § 4.16(a) since January 23, 2003. Nonetheless he was gainfully employed until February 1, 2012 (and therefore was not factually shown to be unemployable prior to that date). Beginning in February 2012, the Veteran's service-connected disabilities have been: status post right TKR [rated] 60 percent; PTSD with major depressive disorder, 50 percent; bronchial asthma, 30 percent; muscle tension headaches associated with PTSD, 10 percent; tinnitus, 10 percent; degenerative joint disease of the left knee, 10 percent; bilateral hearing loss (0 percent, from March 2012); right knee surgical scar, 10 percent (and 0 percent from September 25, 2012). His combined rating from February 1, 2012 was 90 percent . [Since July 23, 2014 (date of left TKR surgery), the combined rating has been 100 percent: initially he received a temporary total rating based on convalescence under 38 C.F.R. § 4.30; from September 1, 2015 he was assigned a 100 percent combined schedular rating. He has also been awarded special monthly compensation under 38 U.S.C. § 1114(s) and 38 C.F.R. § 3.350(i), on account of one disability rated 100 percent and additional service-connected disabilities independently rated 60 percent or more, during the two periods that he was convalescing for TKRs.] In October 2011, the Veteran contacted the RO by telephone and stated that he was unable to maintain employment due to a knee disability and he would be filing a formal VA application. In September 2012, he filed a formal claim on VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, indicating that he became too disabled to work from February 1, 2012. He stated that his disability affected full time employment on January 21, 2012 and that he last worked full time on February 4, 2012. He listed gainful employment from August 2011 to October 2011 and from January 2012 to February 2012. Both positions [obtained during the Veteran's period of convalescence from a right TKR] involved working for manufacturing companies; he stated that the employment was obtained through a VA vocational rehabilitation program, and the job positions were in metal assembly and fabrication. He indicated that he stopped working due to his right knee disability. He had not tried to obtain employment since he became too disabled to work. He completed one year of college and had no additional training or education either before or since he became too disabled to work, except for a course in the military and the VA vocational rehabilitation program that helped prepare him for the metal work. He indicated that he had tried performing the type of work that he had previously done but that his disability did not allow him to maintain such position. The RO denied the Veteran's TDIU claim in October 2012, asserting that his latest VA examination had shown improvement in his right knee disability and the examiner had opined that the disability did not prevent him from sedentary work. The Veteran responded in a November 2012 notice of disagreement letter, stating that he had tried to return to full-time work [after his right TKR] but was unable to maintain a steady job due to right knee pain, headaches, and medication he took for pain. After consideration of the lay and medical evidence, the Board concludes the evidence shows that throughout from February 1, 2012 the Veteran has been unable to maintain substantially gainful employment due to a combination of his service-connected disabilities. SSA records show that the Veteran was awarded disability benefits, as notified in a June 2012 letter. On his Social Security application, the Veteran noted a work history that included spot welding (from 2004 to 2007), material handler and supply clerk (from 2009 to March 2011), and metal fabrication (from August 2011 to February 2012). Prior work history included positions in industry consisting of forklift operation, production (band saw operator), construction (carpenter), labor (loading/packing on trucks), and mail handling. He stated that ever since his right TKR, he had not been able to stand or sit for long periods of time or walk, and that he was unable to maintain a job. On an August 2011 VA fee-basis examination, the Veteran reported that he experienced headaches on the average of two times per week, lasting for four hours. He indicated that he was able to go to work but required medication. As to the effect of the headaches on the Veteran's usual occupation, the examiner stated that the Veteran needed to rest when his headache flared. On a March 2012 VA examination to evaluate the right knee disability, the examiner noted that the Veteran was still having problems with stiffness of the knee and knee pain. Range of motion was limited and there was slight swelling. Recent X-rays showed moderate swelling in the right knee and knee joint effusion (X-rays of the left knee showed mild osteoarthritis). The examiner noted the Veteran's recent work history in manufacturing jobs, which were short-lived due to right knee pain. As a board-certified orthopedic surgeon, the examiner opined that the functional impairment of the Veteran's right knee was severe and that the functional impairment of his left knee was moderate. The examiner described the knee symptoms as including limitation of motion, continued pain and swelling, and daily flare-ups. He related the Veteran's report of the activities that made his right and left knee symptoms worse: walking, climbing stairs or hills, getting out of bed or the shower, rising from a chair, lifting, carrying, picking up items from the floor, and driving. The Veteran indicated that when his knee pain worsened, he stopped the activity and sat or reclined for about four hours. On March 2012 VA psychiatric examination to evaluate the Veteran's service-connected PTSD, the examiner noted that the disability was moderately severe. He assessed the overall impact of the Veteran's present psychological stress as reducing his reliability and productivity, both in social and occupational interactions due to symptoms of PTSD, irritability, outbursts of verbal anger, with a history of depression, anhedonia, and difficulty with motivation. On September 2012 VA fee-basis examinations, the examiner stated that the Veteran's right knee would impair his ability for prolonged standing, walking, climbing/descending stairs, and prolonged and frequent kneeling. Regarding the service-connected bronchial asthma, she stated that it would impact his ability to work because he had to avoid strenuous work or exposure to environmental irritants/chemicals that might trigger asthma attacks. Regarding the service-connected headaches, the examiner concluded that they would impact on ability to work by limiting physical exertion when headaches flared. At the March 2014 Board hearing, the Veteran testified about the limitations of his knees and other disabilities. Based on a VA examiner's opinion, the undersigned indicated that the Board would concede that the Veteran was unable to engage in any work that required prolonged standing or extensive walking. Regarding capability to engage in sedentary work, the Veteran indicated that he could not sit for long periods of time because he experienced knee pain and numbness and had to move around or stand up (his representative observed that throughout the hearing, the Veteran was having a difficult time sitting in the chair and was moving around a lot). The representative also pointed out that the Veteran's PTSD caused him problems while working, in terms of being around loud noises and under supervision. The Veteran added that the medication he took for knee pain and headaches and for PTSD caused drowsiness. An April 2014 letter from a VA physician indicates that the Veteran had "significant disability related to his bilateral knee osteoarthritis." She noted that the Veteran underwent a right TKR in 2010 and subsequently developed prosthesis loosening and inflammation or infection of that joint. She stated that the Veteran also developed left knee arthritis and was currently undergoing treatment for that, to include conservative therapies (joint injections and bracing), but that his pain level and joint instability made it "nearly impossible to safely stand or sit for more than 30 minutes at a time"; she believed it would not be safe for the Veteran to operate heavy machinery. The Board finds that the evidence reasonably supports that the Veteran has not been capable of maintaining substantially gainful employment since February 2012. He completed a year of college (without obtaining a degree), and he has had no specialized training in a profession. Instead, he has engaged in a variety of general industrial and labor-type work in the years before completely stopping working in February 2012. He asserts that he was no longer able to continue working in February 2012 due to right knee symptoms, which is supported by the VA examiner's assessment of severe functional impairment from the right knee shortly after he stopped working. The examiner also described the Veteran's limitations in terms of impairment caused by both knees. Subsequent hearing testimony and medical assessments of functional impairment due to the knees, and other service-connected disabilities, establish that the Veteran's service-connected disabilities, in combination, preclude the Veteran from maintaining the type of work in which he has experience or for which he could feasibly be trained, including sedentary employment. The record reasonably shows that throughout since February 2012 the Veteran's service-connected disabilities have been of such nature and severity as to prevent him from obtaining and maintaining substantially gainful employment, especially considering his level of education, prior work experience, and training. Accordingly, a TDIU rating is warranted. ORDER Service connection for a right hand disability is denied. Service connection for a left hand disability is denied. A TDIU rating is granted, from February 2012, and subject to the regulations governing payment of monetary awards. REMAND The Board deems that further development is necessary with respect to the issues remaining on appeal (seeking ratings for a left knee disability higher than 10 percent prior to July 23, 2014 and higher than 30 percent from September 1, 2015, and extraschedular ratings (under 38 C.F.R. § 3.321(b)) for right knee orthopedic disability and for right knee scarring. In October 2016 the Board remanded the left knee disability rating claim for an examination compliant with a new CAVC decision in Correia v. McDonald, 28 Vet. App. (2016). On November 2016 contract examination the examiner did not report all the requested findings. For example, rather than provide results of range of motion testing for pain on both active and passive motion and in weight-bearing and nonweight-bearing, he appears to have provided only initial range of motion measurements, noting that there was pain with both flexion and extension and with weight-bearing. Further, he commented in the report that "accurate quantification" of passive range of motion was "not possible with a single examiner and was not done" but that pain was present with passive ranging of the knee. He did not explain why the requested findings could not be obtained (i.e., why a single examiner could not accomplish such testing). Therefore, a new Correia-compliant examination is warranted. Regarding the right knee disability extraschedular rating claim, the Board remanded the case to the RO in October 2016 for a medical opinion addressing the matter of whether any current or past pain (interfering with sleep), fluid buildup, or heat was related to the service-connected knee disability (before or after the TKR in December 2010) and resulted in identifiable functional impairment distinct from that contemplated in the schedular rating criteria (such as limitation of motion or instability). The AOJ was to then make an initial determination whether to refer the case to the Director of the Compensation and Pension Service for consideration of an extraschedular rating. On November 2016 contract examination, the examiner remarked that while such symptoms as heat (inflammation/warmth), fluid buildup (effusion), and pain interfering with sleep "can be associated with" the Veteran's service-connected right knee disability, they were either not found on the present examination or currently verifiable. This assessment does not respond to the inquiry as to whether any past pain, fluid buildup, or heat documented in the record was in fact related to the right knee disability and resulted in functional impairment separate from that impairment contemplated by the criteria under which the Veteran was then evaluated. Furthermore, the AOJ referred the case to the C&P Director for extraschedular consideration in July 2017, and the response in August 2017 appears to refer to the left TKR in 2014, rather than the right TKR in 2010, and the decision also appears predicated on the most recent examination findings in November 2016, rather than the findings of heat, fluid buildup, and pain interfering with sleep that were documented in the past. Accordingly, the development of this claim on remand has been inadequate. The case is REMANDED for the following : 1. The AOJ should arrange for the Veteran to be examined by an appropriate physician (preferably an orthopedist) to determine the current severity of his left knee disability and address questions regarding the nature and functional impairment of his complaints of right knee pain (interfering with sleep), fluid buildup, and heat, as specifically discussed in the February 2016 Joint Motion. The Veteran's record must be reviewed by the examiner in conjunction with the examination. All findings should be described in detail. (a) Regarding the left knee, the examination report must include results of range-of-motion studies, with notation of the degree of motion at which the Veteran experiences pain and any additional functional limitations due to such factors as weakness, fatigue, lack of endurance, and incoordination (all including after repetitive use and during flare-ups). To be compliant with Correia v. McDonald, 28 Vet. App. 158 (2016), the range-of-motion testing should, to the extent possible, reflect ranges of motion on active and passive motion as well as in weight-bearing and nonweight-bearing (or the examiner must explain why it is not medically possible or feasible to obtain such findings). Based on examination of the Veteran and review of his record, the examiner should opine whether, since September 1, 2015, the Veteran's post-TKR left knee disability has been manifested by chronic residuals consisting of severe painful motion or weakness. (b) Regarding the right knee, the October 2016 Board Remand summarized that the "Joint Motion found that the record reflects that the Veteran's right knee disability produced (1) "pain that keeps him up at night," (citing a July 2010 VA treatment note); (2) "fluid buildup," (citing March and April 2010 VA treatment notes, a May 2007 private treatment note, and the July 2009 VA Form 9); and (3) heat (citing a November 2008 VA examination report)." The examiner is asked to respond to the following: (i). Are there pain (interfering with sleep), fluid buildup, and/or heat symptoms manifestations associated with either the Veteran's arthritis of the right knee or his right TKR? If so, please specifically identify which of these reported symptoms is found to be currently (or to have been in the past, either before or after the TKR in December 2010) medically associated with the service-connected right knee disabilities. (ii). For each symptom currently found to be (or shown in the past, either before or after the TKR in December 2010) please describe the functional impairments that flow from that symptom manifestation. In particular, any functional impairment that may not be contemplated in VA's schedular disability rating criteria for orthopedic knee disabilities (see 38 C.F.R. § 4.71a, Diagnostic Codes 5256-5261, relative to ankylosis; recurrent subluxation or lateral instability; cartilage symptoms of dislocation, episodes of locking, pain and effusion into the joint; and limitation of flexion and/or extension) should be specifically noted and discussed. The examiner should explain the rationale for all opinions. 2. Thereafter, regarding extraschedular ratings for right knee orthopedic disability and right knee scarring, the AOJ should make a formal determination as to whether referral of the case to the Director of the Compensation and Pension Service for consideration of an extraschedular rating is warranted. If referral is deemed warranted, the AOJ should proceed with the referral. 3. Upon completion of the foregoing, the AOJ should readjudicate the claims seeking increased ratings for a post-TKR left knee disability and extraschedular ratings for a right knee disability. If either remains denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and his representative opportunity to respond, and return the case to the Board. 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 remanded by the Board or by CAVC for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs