Citation Nr: 18141280 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 13-25 519 DATE: October 10, 2018 ORDER Entitlement to service connection for prostate condition, to include residuals of prostate cancer, benign prostatic hypertrophy (BPH) and prostatitis, is denied. Entitlement to a rating in excess of 10 percent disabling for right knee disability is denied. Entitlement to a rating in excess of 10 percent disabling prior to March 1, 2016, and in excess of 30 percent disabling as of May 1, 2017, for left knee disability is denied. Entitlement to a compensable rating for bilateral hearing loss is denied. REMANDED Entitlement to service connection for bilateral hand condition, to include arthritis and carpal tunnel syndrome, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s diagnosed prostate disorder did not originate in service, within a year of service, and is not otherwise etiologically related to the Veteran’s active service, to include as due to herbicide or jet fuel exposure. 2. During the period on appeal, the Veteran’s right knee disability was manifested by pain; the right knee disability was not manifested by flexion limited to 60 degrees or less, extension limited to 5 degrees or less, ankylosis, recurrent subluxation, instability, dislocation or a meniscal condition. 3. Prior to March 1, 2016, the Veteran’s left knee disability was manifested by pain; the left knee disability was not manifested by flexion limited to 60 degrees or less, extension limited to 5 degrees or less, ankylosis, recurrent subluxation, instability, dislocation or a meniscal condition. 4. As of May 1, 2017, the Veteran’s left knee disability was manifested by pain; the left knee disability was not manifested by flexion limited to 60 degrees or less, extension limited to 5 degrees or less, ankylosis, recurrent subluxation, instability, dislocation or a meniscal condition. 5. During the period on appeal, the Veteran manifested no worse than level II hearing loss in the right ear, and no worse than level II hearing loss in the left ear. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a prostate condition have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2018). 2. The criteria for a rating in excess of 10 percent disabling for right knee disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5010 5003, 5055, 5256-5263 (2018). 3. The criteria for a rating in excess of 10 percent disabling prior to March 1, 2016, and in excess of 30 percent disabling as of May 1, 2017, for left knee disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, DCs 5010, 5055, 5256-5263 (2018). 4. The criteria for a compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.10, 4.85, 4.86, DC 6100 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1972 to May 1986. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a February 2010 rating decision by a Department of Veterans Affairs Regional Office (RO). In June 2016, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. In November 2016, the Board remanded this case. During the pendency of the appeal, an April 2017 rating decision granted service connection for major depressive disorder (MDD) to include alcohol use disorder. Therefore, as the RO granted the benefits sought on appeal, those issues are no longer before the Board. Shoen v. Brown, 6 Vet. App. 456 (1994). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of the disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. 3.307, 3.309(a). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for a prostate condition. The Veteran seeks entitlement to service connection for a prostate condition, to include residuals of prostate cancer, BPH and prostatitis. Specifically, the Veteran asserts that his prostate condition was caused by exposure to jet fuel during service. Alternatively, the Veteran asserts that his prostate cancer is secondary to herbicide exposure while he was stationed in Korea. The Veteran’s STRs show he was treated for a slightly enlarged prostate with symptoms of pain in July 1975. The Veteran’s military personnel record shows he served in Korea from July 1980 to January 1981. In a February 2009 VA medical record, the Veteran reported that he had an enlarged prostate that dated back to the late 1990’s and that it had become more enlarged since that time. He further reported being assessed with prostatitis at that time. In addition, he reported having an elevated PSA level in the late 1990’s and that he could not recall his PSA level decreasing below level 4 since that time. Another February 2009 VA medical record noted a history of an enlarged prostate, elevated PSA levels and a current diagnosis of prostatitis. A July 2009 VA prostate biopsy revealed a diagnosis for adenocarcinoma. The Veteran underwent a VA examination in September 2009. The examiner noted a history of prostatitis and adenocarcinoma of the prostate. The examiner also noted a documented episode of prostatitis in 1975 during service and the next episode in 1996. Accordingly, the examiner noted a 21-year absence of prostatitis and, thus, no continuity of the condition since service. Based on the above, the examiner opined that it was not at least as likely that the Veteran’s current prostate condition was related to the single episode of prostatitis during service. In September 2009, the Veteran underwent a radical retropubic prostatectomy with bilateral peripheral lymph node dissection. In his VA Form 9, received May 2013, the Veteran asserted that he was exposed to herbicides while stationed along the DMZ in Korea. Specifically, the Veteran asserted his belief that herbicide chemicals sprayed between 1968 and 1971 were still active while he was stationed in Korea and that he was thereby exposed to active chemical agents. The Veteran further asserted exposure to jet fuel while inspecting and loading aircraft during his assignment as a jump master instructor. At a June 2016 Board hearing, the Veteran testified that he believed his prostate cancer resulted from exposure to jet fuel due to his MOS as a jumpmaster which required him to be constantly around aircraft. Specifically, the Veteran asserted he was exposed to JP-4 jet fuel which had some of the same components of Agent Orange. The Veteran also testified that he did not serve in Vietnam. At a January 2017 VA examination, the Veteran reported being seen for prostatitis around 1973/1974 which was treated with antibiotics. The Veteran further reported being treated for prostatitis over 20 times during the following 30 years. In addition, the Veteran reported an elevated PSA level around 1997 at which time he was treated for prostatitis. He related his prostate problems to jet fuel exposure during service. The examiner opined that the Veteran’s prostate cancer was “less likely than not (less than 50% probability)” etiologically related to the in-service prostate condition. The examiner further opined that the residuals of prostate cancer was “less likely than not (less than 50% probability)” related to service including due to exposure to JP-4 jet fuel. In support of her opinion, the examiner initially found that the medical evidence did not support a 2009 diagnosis of either prostatitis or BPH. Instead, the examiner found the Veteran had a diagnosis of prostate cancer at that time as shown by elevated PSA levels and lower urinary tract symptoms. The examiner further noted that the STRs only noted one incidence of prostatitis in July 1975 and further noted a ruled-out prostatitis in June 1977 and April 1991. The examiner further noted that the medical literature did not support an etiological association between prostate cancer and/or prostatitis and exposure to jet fuel, including JP-4, or an association between prostatitis and the development of cancer. Instead, the examiner noted multiple occasions the Veteran was treated for STDs during service and that STDs can cause prostatitis. Thus, the examiner determined that the in-service prostatitis was etiologically related to his STD and not jet fuel exposure. In February 2017, the Veteran submitted medical literature on the health effects of jet fuel including JP-4 in animals including mice and rats. The article noted that no studies were located regarding cancer in humans in relationship to exposure to JP-4, including inhalation, oral, dermal, or chronic-duration exposure. Additionally, the medical literature noted that the current animal data regarding the carcinogenicity of JP-4 was equivocal and that the evidence was insufficient to draw conclusions regarding the carcinogenic potential of JP-4 in humans. After a review of the evidence of record, the Board finds that service connection for a prostate condition is not warranted. Initially, the Board notes that VA regulations provide that certain diseases associated with exposure to herbicide agents may be presumed to have been incurred in service even if there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 C.F.R. § 3.309(e). Absent affirmative evidence to the contrary, there is a presumption of exposure to herbicides (to include Agent Orange) for all Veterans who served in the Republic of Vietnam during the Vietnam Era. See 38 U.S.C. § 1116(f) and 38 C.F.R. § 3.307(a)(6)(iii). While the Veteran served during the Vietnam Era, the evidence does not show that he served in the Republic of Vietnam. Importantly, the Veteran denied having served in Vietnam. Instead, the Veteran asserts that he was exposed to herbicides while stationed in Korea. Regulations provide that a Veteran is presumed to have been exposed to herbicides in Korea if the evidence shows he was in a unit that operated in or near the Korean DMZ in an area in which herbicides are known to have been applied between April 1, 1968, and August 31, 1971. 38 C.F.R. 3.307(a)(6)(iv). As the evidence does not show the Veteran served in Korea between April 1, 1968, and August 31, 1971, the presumptive provision does not apply. Accordingly, the Board concludes that the evidence of record does not support a finding of exposure to herbicides during service and will not further consider the Veteran’s service connection claim on a secondary basis due to herbicide exposure. Turning to the Veteran’s assertion that his prostate condition is otherwise related to service, to include as due to jet fuel exposure, the Board notes there is sufficient evidence the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Specifically, during the pendency of the appeal, the Veteran was diagnosed with prostate cancer for which he underwent a radical retropubic prostatectomy with bilateral peripheral lymph node dissection. The evidence of record further shows treatment for prostatitis during service. Therefore, the remaining question on appeal is whether the Veteran’s diagnosed prostate cancer is otherwise related to service. In this regard, the Board finds the January 2017 VA examination the most probative evidence of record. The examiner opined that the Veteran’s prostate cancer was “less likely than not (less than 50% probability)” etiologically related to service, including as due to JP-4 jet fuel exposure or related to his in-service treatment for prostatitis. Importantly, the examiner found the Veteran did not have a diagnosis for either prostatitis or BPH in 2009. Instead, the examiner concluded that the 2009 prostate condition was symptomatic of his later diagnosis for prostate cancer. Moreover, the examiner noted that prostatitis did not cause prostate cancer, as supported by the medical literature. With regard to exposure to JP-4 jet fuel, the examiner also noted that the medical literature did not support an etiological association. The examiner additionally found that the in-service diagnosis for prostatitis was related to his acquired STDs and not environmental jet fuel exposure. The Board finds that the examiner provided a detailed discussion of the medical evidence, the medical conclusions reached and the opinions offered, and she provided adequate rationales for such opinions rendered. The Board recognizes the Veteran’s submitted medical literature regarding various jet fuels, to include JP-4, and adverse health effects. However, the medical literature noted no medical studies were located regarding JP-4 exposure and cancer in humans. The submitted medical literature additionally concluded that the current animal data was equivocal and evidence insufficient to draw conclusions regarding the carcinogenic potential of JP-4 in humans. Thus, the submitted medical literature does not support the Veteran’s assertion that his exposure to JP-4 caused his prostate cancer. The Board further recognizes the Veteran’s lay statements linking the onset of his prostate condition to jet fuel exposure. With regard to lay evidence of a nexus, lay persons are not categorically incompetent to speak on matters of medical diagnosis or etiology. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In this vein, the Board must consider the type of condition specifically claimed and whether it is readily amenable to lay diagnosis or probative comment on etiology. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Veteran is competent to report purported symptoms such as pain. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). However, without evidence showing that he has medical training or expertise, he cannot competently provide a medical nexus opinion between a current diagnosis, residuals of prostate cancer, and an in-service event such as jet fuel exposure. 38 C.F.R. § 3.159(a)(1)-(2); Jandreau v. Nicholson, 492 F.3d 1372 (2007). In any event, to the extent the Veteran may be competent to opine as to medical etiology, the Board finds that the Veteran’s lay assertions in the present case are outweighed by the January 2017 VA medical examiner’s opinion, who determined that there was no nexus between the Veteran’s prostate condition and service. The examiner has training, knowledge, and expertise on which she relied to form her opinions, and she provided persuasive rationales for them. The Board further finds that the January 2017 VA examination report is bolstered by the negative September 2009 VA examination report. Importantly, there is no medical evidence to the contrary. Accordingly, the Board finds that a preponderance of the evidence is against the Veteran’s claim for service connection for a prostate condition. In arriving at this conclusion, the Board has considered the doctrine of reasonable doubt, but finds that the preponderance of the evidence is against a finding of entitlement to service connection; the claim is therefore denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When rating musculoskeletal disabilities on the basis of limited motion of a joint, VA must consider functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 and 4.45 are to be considered only in conjunction with diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). Painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Where functional loss is alleged due to pain upon motion, the function of the musculoskeletal system and movements of joints must still be analyzed. DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80 (1997). Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The regulations preclude the assignment of separate ratings for the same manifestations under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1995). 2. Entitlement to increased ratings for bilateral knee disability. The Veteran asserts entitlement to a rating in excess of 10 percent disabling for a right knee disability. The Veteran additionally asserts entitlement to a rating in excess of 10 percent disabling prior to March 1, 2016, and in excess of 30 percent disabling as of May 1, 2017, for left knee disability. The Board notes that a temporary 100 percent rating based on surgery requiring convalescence was granted which assigned a 100 percent disability rating from March 1, 2016 to May 1, 2017. That rating is not on appeal. The Veteran filed his current bilateral knee increased rating claim in April 2009. The evidence of record includes a September 2009 VA examination in which the Veteran reported that he had not received treatment for his condition. He reported bilateral knee symptoms of weakness, stiffness, swelling, giving way, lack of endurance, tenderness and pain. The Veteran additionally reported symptoms of locking for his right knee. He denied experiencing heat, redness, fatigability, deformity, drainage, effusion, subluxation and dislocation. He further reported flare-ups once per month with each episode lasting one-week. Pain was rated an 8 on a scale to 10. Flare-ups reportedly did not result in functional impairment or any limitation of motion. An examination of the bilateral knee revealed no signs of edema, instability, abnormal movement, effusion, weakness or subluxation. No genu recurvatum, locking pain or ankylosis was found. ROM testing of the right knee revealed flexion to 140 degrees with pain noted at 80 degrees, and extension to 0 degrees with pain noted at 20 degrees. ROM testing of the left knee revealed flexion to 140 degrees with pain noted at 110 degrees and extension to 0 degrees with pain noted at 60 degrees. Bilateral knee joint function was further found limited by pain, fatigue, weakness, lack of endurance and incoordination following repetitive use. March and October 2010 VA medical records noted full ROM for the bilateral knee with no meniscal or ligamental tears or joint effusions. During a December 2010 VA examination the Veteran’s bilateral knee disability was manifested by flexion to 120 degrees and extension to 0 degrees. Pain was noted after repetitive use, but no other limitations. An April 2012 VA physical therapy record noted that the right knee was manifested by flexion to 112 degrees and extension to 0 degrees. The left knee was found manifested by flexion to 122 degrees and extension to 0 degrees. Pain was reported a 5 on a scale to 10 with pain that would reportedly come and go. The Veteran was noted to use bilateral hinged knee braces and a cane for ambulation. The Veteran further reported that he tried walking 30 minutes 1-2 times per day. In August 2013, the Veteran’s left knee was noted to have swelling over the medial joint line. No medial collateral ligament (MCL) or lateral collateral ligament (LCL) instability was found. Negative anterior and posterior drawer tests were also noted. The right knee was found manifested by minimal swelling over the medial joint line with a negative McMurray’s test and was also noted as negative for MCL or LCL instability. In September 2013, the Veteran reported that his right knee locked and gave way. The physician noted full ROM with mild pain and crepitus. No deformity or ligament laxity was found and the right knee negative McMurray’s test was noted. At a January 2017 VA examination, the Veteran’s bilateral knee disability was manifested by flexion to 140 degrees and extension to 0 degrees. No pain was noted during the examination including during weight-bearing. Additionally, no additional functional loss was noted after three repetitions. The Veteran did report moderate to severe pain in both flexion and extension in both knee. Flare-ups reportedly caused increased bilateral knee pain from baseline in both flexion and extension. Muscle strength testing was noted as normal bilaterally. No ankylosis was found. The Veteran’s bilateral knee disability was additionally not found manifested by subluxation, instability, recurrent effusion, recurrent patellar dislocation or a meniscal condition. The Veteran reported flare-ups that occurred if he stooped or bended his knees resulting in increased pain and swelling. Additionally, the Veteran reported that his bilateral knee disability limited his ability to drive over 1.5 miles or walk or stand over 30 minutes. The examiner found that the bilateral knee disability limited the Veteran’s ability to perform some physical activities such as lifting, carrying, pushing, pulling, walking, standing, bending, twisting, squatting, climbing or driving. The examiner did not find that the bilateral knee disability precluded sedentary activities. Prior to March 1, 2016, the Veteran’s left knee disability has been rated 10 percent disabling pursuant to 38 C.F.R. § 4.71a, DC 5260-5010. The Veteran’s right knee has also been rated 10 percent disabling pursuant to 38 C.F.R. § 4.71a, DC 5260-5010. Accordingly, the Veteran’s bilateral knee has been rated by analogy for limitation of flexion based on painful motion. Since May 1, 2017, the Veteran’s left knee disability has been rated pursuant to 38 C.F.R. § 4.71a, DC 5055 for knee replacement (prosthesis). Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (cartilage, semilunar, dislocated with frequent episodes of “locking” pain, and effusion into the joint), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). Initially, the Board notes that the Veteran’s bilateral knee disability has not been manifested by ankylosis, impairment of the tibia and fibula or genu recurvatum at any time during the periods on appeal; therefore, DCs 5256, 5262 and 5263 are not for application. Under DC 5257, other impairment of the knee, a 10 percent evaluation requires slight recurrent subluxation or lateral instability. A 20 percent evaluation requires moderate recurrent subluxation or lateral instability and a 30 percent evaluation requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Under DC 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under DC 5260, limitation of flexion to 60 degrees warrants a non-compensable evaluation, and limitation of flexion to 45 degrees warrants a 10 percent evaluation. Limitation of flexion to 30 degrees warrants a 20 percent evaluation, and limitation of flexion to 15 degrees warrants a 30 percent evaluation. 38 C.F.R. § 4.71a. DC 5261 provides the rating criteria for limitation of extension of the leg. Under this diagnostic code, extension that is limited to 5 degrees is noncompensable; extension that is limited to 10 degrees warrants a 10 percent disability rating; and extension limited to 15 degrees warrants a 20 percent disability rating. Extension limited to 20 degrees warrants a 30 percent disability rating; extension limited to 30 degrees warrants a 40 percent disability rating; and extension limited to 45 degrees warrants a 50 percent disability rating. 38 C.F.R. § 4.71a. VA’s General Counsel (GC) has interpreted that a veteran who has arthritis and instability of the knee could receive separate ratings under DCs 5003 and 5257. VAOPGCPREC 23-97. In VAOPGCPREC 9-98, the VA GC explained that, when a veteran has a knee disability evaluated under DC 5257, to warrant a separate rating for arthritis based on x-ray findings, the limitation of motion need not be compensable under DC 5260 or DC 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. In VAOPGCPREC 9-2004, the VA GC held that, when considering DCs 5260 and 5261 together with 38 C.F.R. § 4.71, a veteran may receive a rating for limitation in flexion only, limitation of extension only, or separate ratings for limitations in both flexion and extension under DC 5260 and DC 5261. Additionally, the United States Court of Appeals for Veterans Claims addressed whether separate ratings could be assigned under DCs 5257 and DC 5258, which evaluates dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion in the joint, and DC 5259 (semilunar cartilage removal, symptomatic). The Court held that evaluation of a knee disability under DC’s 5257 or 5261 or both does not, as a matter of law, preclude separate evaluation of a meniscal disability of same knee under DC 5258 or 5259, and vice versa. Lyles v. Shulkin, 29 Vet. App. 107, 112-113 (2017). The Court further held that entitlement to a separate evaluation in a given case depends on whether the manifestations of disability for which a separate evaluation is being sought have already been compensated by an assigned evaluation under a different DC. Id. The Board will first address the Veteran’s service-connected right knee disability. After a review of the evidence of record, the Board finds that a rating in excess of 10 percent disabling is not warranted. During the period on appeal, the Veteran’s right knee disability has not been found manifested by flexion limited to 30 degrees or extension limited to 5 degrees. Thus, a higher rating under DC 5260 is not warranted, nor is a compensable rating under 5261. In addition, while the Veteran has reported symptoms of giving way during his VA examinations, neither examiner has found the right knee manifested instability or subluxation upon examination. Absent evidence of recurrent subluxation or lateral instability, the Board finds that the criteria for a separate evaluation under DC 5257 has not been met. Additionally, the evidence of record does not demonstrate a right knee disability manifested by dislocation or a meniscal condition. Thus, a compensable rating under DCs 5258 or 5259 is not warranted. According, the Board finds that a rating in excess of 10 percent disabling for a right knee disability is not warranted during the period on appeal. Similarly, prior to March 1, 2016, the Veteran’s left knee has not been found manifested by flexion limited to 30 degrees or extension limited to 5 degrees. Thus, higher ratings under DC 5260 or 5261 are not warranted. Additionally, the Veteran did not report left knee symptoms of giving way, nor has his left knee been found manifested instability or subluxation. Absent evidence of recurrent subluxation or lateral instability, a separate evaluation under DC 5257 is not warranted. Additionally, during this period on appeal the left knee disability was not manifested by dislocation or a meniscal condition. Thus, a compensable rating under DCs 5258 or 5259 is not warranted prior to March 1, 2016. According, the Board finds that a rating in excess of 10 percent disabling for left knee disability prior to March 1, 2016 is not warranted. Turning to the period on appeal as of May 1, 2017; following the Veteran’s convalescence from left knee surgery, the left knee disability has been rated 30 percent disabling under DC 5055 for prosthetic replacement of knee joint. Under DC 5055, prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. 4.30. Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to DCs 5256, 5260, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. 38 C.F.R. 4.71a, DC 5055. After a review of the evidence of record, the Board finds that the Veteran’s left knee disability is properly rated at 30 percent. As noted above, the Veteran underwent a total left knee arthroplasty in March 2016. As further noted above, following prosthetic replacement of a knee joint and following the one-year total rating under 38 C.F.R. 4.30, the left knee is to be rated pursuant to residuals with the minimum rating set at 30 percent. 38 C.F.R. 4.71a, DC 5055. The Veteran underwent a VA examination in January 2017 which showed normal strength and stability. No localized pain or pain on palpation was found, nor was pain with weight bearing. The Veteran did report flare-ups that occurred if he stooped or bended his knees resulting in increased pain and swelling. ROM testing revealed flexion to 140 degrees and extension to 0 degrees with no painful motion elicited. Based on the above, the Board finds that a rating in excess of 30 percent under DC 5055 is not warranted as the left knee disability was not manifested by chronic severe painful motion or weakness. Additionally, the Board notes that based on the findings contained in the January 2017 VA examination report, non-compensable ratings would be warranted under DC 5256, 5260, 5261, or 5262 if the left knee disability was rated by analogy under any of those diagnostic codes. Therefore, rating the Veteran’s left knee disability by analogy does not provide him with a more beneficial outcome. The Board further finds that there is no basis for the assignment of any higher rating based on consideration of functional loss of the either knee during any period on appeal. 38 C.F.R. 4.40, 4.45, 4.59; Deluca, 8 Vet. App. at 204-06; Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011); Correia, 28 Vet. App. at 158. Even with the Veteran’s assertions of pain, flare-ups and functional limitation, he has not demonstrated limitation of extension or flexion of either knee to warrant the assignment of any higher evaluation. Therefore, the evidence reflects that the currently assigned 10 and 30 percent ratings properly compensate him for the extent of functional loss resulting from painful motion, stiffness, and tenderness in the bilateral knee. In sum, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent for the service-connected right knee disability. Prior to March 1, 2016, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent for left knee disability and that claim is denied. Finally, as of May 1, 2017, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 30 percent for left knee disability and that claim is denied. 38 U.S.C. 5107(b); 38 C.F.R. 4.7, 4.71a, DCs 5002, 5003, 5055, 5256-5263; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to a compensable rating for bilateral hearing loss. The criteria for rating hearing impairment requires the consideration of the results of examinations using controlled speech discrimination tests (Maryland CNC) with the results of puretone audiometry tests. The results are charted on Table VI and Table VII, as set forth in the Rating Schedule. In order to establish entitlement to a higher rating for hearing loss it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average puretone decibel loss are met. 38 C.F.R. § 4.85. Hearing tests will be conducted without hearing aids. When the puretone threshold at 1000, 2000, 3000, and 4000 Hertz are each 55 decibels or more, or when the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, those exceptional patterns of hearing require different methods of rating. 38 C.F.R. § 4.86. A review of the evidence of record shows the Veteran underwent a VA examination in June 2008. The examiner noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 40 80 105 LEFT 25 10 5 60 85 The average puretone threshold in the right ear was 53 decibels and 37 decibels in the left ear. Word recognition scores were 88 percent bilaterally. The Veteran underwent another VA examination in September 2009. The examiner noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 40 80 85 LEFT 10 15 15 50 85 The average puretone threshold in the right ear was 50 decibels and 35 decibels in the left ear. Word recognition scores were 100 percent bilaterally. At a January 2017 VA examination, the following audiometric testing results were noted: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 40 85 95 LEFT 5 10 10 55 85 The average puretone threshold in the right ear was 49 decibels and 33 decibels in the left ear. Word recognition scores were 94 percent for the right ear and 92 percent for the left ear. Turning to the results of the June 2008 VA audiological examination, the findings correlate to a designation of level II in the right ear, and level II in the left ear. Those results provide for a non-compensable rating under DC 6100. Turning to the results of the September 2009 VA audiological examination, the findings correlate to a designation of level I in the right ear, and level I in the left ear. Those results provide for a non-compensable rating under DC 6100. Turning to the results of the January 2017 VA audiological examination, the findings correlate to a designation of level I in the right ear, and level I in the left ear. Those results provide for a non-compensable rating under DC 6100. No exceptional pattern of hearing loss was demonstrated at any time during the appeal period. The Board emphasizes that disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). To the extent the Veteran may argue or suggest that the clinical data supports an increased disability rating or that the rating criteria should not be employed, he is not competent to make that assertion. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). As indicated, the rating of hearing loss disabilities requires the administration of audiometric testing that is administered and interpreted by a professional. In sum, the examinations document that during the entire period on appeal the bilateral hearing loss was, at most, subject to a non-compensable disability rating. Consequently, the preponderance of the evidence is against a compensable rating and the claim is denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND The Veteran seeks entitlement to service connection for a bilateral hand condition (claimed as osteoarthritis). In his VA Form 9, received May 2013, the Veteran asserted that his bilateral hand condition was due to his military occupational specialty (MOS) as a paratrooper and three years as a drill sergeant. Alternatively, the Veteran assets that his bilateral hand condition is due to cold weather exposure during service. In a January 2017 VA examination report, examiner noted a diagnosis for bilateral carpal tunnel syndrome (CTS). No arthritis was found. The examiner opined that the diagnosed bilateral CTS was “less likely than not (less than 50% probability)” incurred in or caused by service, to include as due to exposure to cold temperatures. In support of her opinion, the examiner noted no diagnosis for arthritis and further noted that cold exposure did not cause CTS. The examiner further noted that medical literature noted the following as to the causes of CTS: heredity; repetitive hand use; and activities involving extreme flexion and extension of the hand. However, the examiner did not offer a medical opinion as to whether the Veteran’s diagnosed bilateral CTS is otherwise related to service, to include whether the condition is due to the Veteran’s MOS as a paratrooper or drill sergeant. Accordingly, the Board finds the January 2017 VA examination incomplete and an addendum opinion is necessary to properly adjudicate this issue on appeal. Lastly, entitlement to a TDIU is inextricably intertwined with the Veteran’s claim on appeal. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran’s VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. Refer the Veteran’s claims file to the VA examiner who provided the January 2017 VA bilateral hand examination. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s diagnosed bilateral hand disability was causally or etiologically related to his service, to include as due to his military occupational specialty. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. Thereafter, the RO should readjudicate the claims on appeal, to include the claim for a TDIU. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Lamb, Associate Counsel