Citation Nr: 18148824 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-37 639 DATE: November 8, 2018 ORDER Entitlement to an initial rating in excess of 30 percent for insomnia is denied. Entitlement to a compensable rating for residuals of hernia surgery is denied. Entitlement to a separate initial rating of 10 percent for scar, status post hernia surgery is granted. Entitlement to a compensable rating for urethritis is denied. Entitlement to a rating in excess of 10 percent for chronic low back pain is denied. Entitlement to a rating in excess of 10 percent for right knee patellar tendonitis is denied. Entitlement to a rating in excess of 10 percent for left knee patellar tendonitis is denied. Entitlement to a rating in excess of 50 percent for chronic sinusitis status post septoplasty is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is denied. FINDINGS OF FACT 1. The Veteran’s insomnia is not shown to have been manifested by impairment greater than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to chronic sleep impairment, daytime hypersomnolence, fatigue, irritability, concentration difficulties, and subjective mild memory difficulties. 2. The Veteran has no detectable inguinal hernia or residuals from his previous right inguinal hernia repair. 3. The Veteran’s scar, status post hernia surgery is manifested by a painful scar, but not by three or more painful or unstable scars. 4. The Veteran’s urethritis is asymptomatic. 5. The Veterans low back disability was manifested by, at worst, flexion to 85 degrees with back spasms that did not result in abnormal gait or spinal contour and/ or without evidence of intervertebral disc syndrome (IVDS) with incapacitating episodes lasting at least four weeks or more. 6. The Veteran’s right knee disability has been manifested primarily by pain that required the use of a brace or cane and forward flexion to, at worse, 135 degrees and extension to zero degrees. 7. The Veteran’s left knee disability has been manifested primarily by pain that required the use of a brace or cane and forward flexion to, at worse, 105 degrees and extension to zero degrees. 8. The Veteran’s sinusitis is rated at 50 percent which is the maximum schedular rating for sinusitis; the symptoms and their severity are fully accounted for by the schedular rating assigned. 9. The Veteran is not precluded from securing or following all forms of substantially gainful employment due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 30 percent for insomnia have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.27, 4.130, Diagnostic Code (DC) 9440. 2. The criteria for a compensable rating for residuals of hernia surgery have not been met. 38 U.S.C. § 1155, 38 C.F.R. § 3.102, 4.1, 4.2, 4.3, 4.114, DC 7338. 3. The criteria for a separate initial 10 percent rating, but no higher, for scar, status post hernia surgery, have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, DC 7800, 7804. 4. The criteria for a compensable rating for urethritis have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.115a, 4.115b, DC 7525. 5. The criteria for a disability rating in excess of 10 percent for patellar tendonitis, right knee based on instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, DC 5024, 5257, 5260, 5261. 6. The criteria for a disability rating in excess of 10 percent for patellar tendonitis, left knee based on instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.71a, DC 5024, 5257, 5260, 5261. 7. The criteria for a disability rating in excess of 10 percent for back disability have not been met. 38 U.S.C. §1155; 38 C.F.R. § 4.71a, DC 5237-5243. 8. The criteria for a disability rating in excess of 50 percent for sinusitis have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.97, DC 6512. 9. The criteria for TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 2005 to June 2009. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of the disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In determining the propriety of an initial disability rating, the evidence since the effective date of the grant of service connection must be evaluated and staged ratings must be considered. Fenderson v. Brown, 12 Vet. App. 119, 126-27 (1999). 1. Entitlement to a rating in excess of 30 percent for insomnia The Veteran’s insomnia is rated under the General Rating Formula for Mental Disorders (General Formula). Under the General Rating Formula for Mental Disorders, a 30 percent disability rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; or, mild memory loss (such as forgetting names, directions, or recent events). A 50 percent disability rating is warranted for occupational and social impairment with reduced reliability and productivity due to symptoms such as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgement; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9440. The Board acknowledges the psychiatric symptoms listed in the rating criteria are not exhaustive, but are examples of typical symptoms for the listed disability rating. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013); see also Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Analysis The Veteran contends that his insomnia is more severe than the 30 percent rating depicts. From December 2014, the Veteran was seen at the Loma Linda HCS. The Veteran’s records note that during his appointments, he was adequately groomed and wearing casual attire. His motor activity was within normal limits. He was cooperative and polite, and made good eye-contact. His speech was of normal rate, rhythm, and volume. His thought was logical and goal-oriented, and he denied any suicidal or homicidal ideation and auditory or visual hallucinations. His mood was either good or euthymic. He had a full-range of affect. He was alert and oriented times four. His attention was good and insight and judgment were either intact or fair. In January 2017, the Veteran stated that he exercised/ran three or four miles every other day. In September 2015, the Veteran was afforded a VA examination to determine the nature and etiology of his insomnia. The examiner reviewed the Veteran’s files and performed an in-person examination. The Veteran stated that he served five years in the Marines and was treated for insomnia. He stated that he now suffers from consistent insomnia and reported obtaining two to three hours of uninterrupted sleep per night. The examiner confirmed the Veteran’s insomnia diagnosis. The Veteran did not have more than one diagnosed mental disorder. The Veteran’s symptoms included chronic sleep impairment. There were no other symptoms attributable to the Veteran’s condition. The Veteran was capable of managing his financial affairs. The Veteran experienced occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during period of significant stress, or; symptoms controlled by medication. In June 2017, the Veteran was afforded a VA examination to determine the severity of his insomnia. The examiner reviewed the Veteran’s file and performed an in-person examination. The Veteran lived with his wife. He enjoyed having conversations and living with his wife; however, he became quickly agitated with her. The Veteran and his wife got together with her family for family activities. The examiner confirmed the Veteran’s insomnia diagnosis. The Veteran was dressed appropriately, and he exhibited good personal hygiene. He had clear cognition, non-defensive response to questions, and reported information without evidence of manipulation or exaggeration. His thought process was logical and goal directed. His speech pattern was within normal limits. He made and maintained good eye contact. He was able to tract the conversation during the interview and provided a coherent history. His judgement and insight were intact. His mood was euthymic, and his affect was within normal limits. There was no evidence of suicidal or homicidal ideation, auditory or visual hallucinations, or thought disorder. The Veteran did not have more than one diagnosed mental disorder. His symptoms included chronic sleep impairment and mild memory loss, such as forgetting names, directions, or recent events. He was also irritable and short tempered. He denied a history of legal problems. He was capable of managing his financial affairs. The Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation. The Board finds that the VA examination reports and treatment records provide highly probative evidence against a rating in excess of 30 percent. Neither the examination reports nor the treatment records provide medical findings that show occupational and social impairment with reduced reliability and productivity consistent with a 50 percent disability rating. The Veteran’s symptoms included chronic sleep impairment, mild memory loss, and irritability and short temper. The 2017 VA examiner and/or the treatment records notes that during the Veteran’s consults, he was dressed appropriately and exhibited good personal hygiene. He had clear cognition, non-defensive response to questions, and reported information without evidence of manipulation or exaggeration. His thought process was logical and goal directed. His speech pattern was within normal limits. He made and maintained good eye contact. He was able to tract the conversation during the interview and provided a coherent history. His judgement and insight were intact or fair. His mood was euthymic or good, and his affect was within normal limits. There was no evidence of suicidal or homicidal ideation, auditory or visual hallucinations, or thought disorders. The Veteran’s insomnia symptoms included chronic sleep impairment, mild memory loss, irritability and short tempered. However, there was no suggestion that the Veteran experienced irritability to the degree that it has been manifested by violence. Therefore, the Board finds that the frequency, duration, and severity of the symptoms more nearly approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Board has considered the Veteran and his representative’s statements regarding the Veteran’s insomnia. However, as lay persons, the Veteran and his representative do not have the training or expertise to render a competent opinion which is more probative than the VA examiners’ opinions and the evidence of record, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions are outweighed by the evidence of record, to include the VA opinions. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court’s conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert’s opinion more probative on the issue of medical causation). In sum, the preponderance of the evidence is against the assignment of a rating in excess of 30 percent for insomnia. 2. Entitlement to a compensable rating for residuals of hernia surgery The Veteran’s service-connected hernia is rated as non-compensable under 38 C.F.R. § 4.114, DC 7338. Under DC 7338, a non-compensable evaluation is appropriate if the hernia is small, reducible, or without true hernia protrusion; or where it is not operated, but remediable. A 10 percent evaluation is warranted if a hernia is postoperative recurrent, readily reducible and well supported by truss or belt. A 30 percent evaluation is warranted for a small, postoperative recurrent hernia, or unoperated irremediable hernia that is not well-supported by truss, or not readily reducible. A maximum schedular evaluation of 60 percent is warranted for a large, postoperative recurrent hernia that is not well-supported under ordinary conditions and not readily reducible, when it is considered inoperable. Analysis The Veteran contends that his residuals of hernia is more severe than the rating depicts. In March 2015, the Veteran was afforded a VA examination to determine the severity of his disability. The examiner reviewed the claims file and performed an in-person examination. The Veteran stated that in 2008, he began experiencing right lower abdominal pain accompanied with heavy lifting. He was diagnosed with a right inguinal hernia and treated with a laparoscopic hernia repair. His recovery was uneventful; however, he stated that he experienced pain around the surgical site. The examiner confirmed the Veteran’s inguinal hernia diagnosis. The Veteran took medication for his hernia. The examiner did not detect inguinal hernia either on the Veteran’s left or right. The Veteran had a surgical scar related to the Veteran’s hernia. However, the scar was not painful and/or unstable, or the total area of all related scars were not greater than 39 square cm (6 square inches). From August 2015, the Veteran’s treatment records note complaints and treatment for painful hernia. In June 2017, the Veteran was afforded a VA examination to determine the severity of the Veteran’s hernia. The examiner conducted an in-person examination. The Veteran stated that his hernia symptoms began in 2007 and underwent surgery for right inguinal hernia. The examiner confirmed the Veteran’s status post hernia surgery. However, the VA examiner did not detect a hernia. The examiner stated that the condition had resolved. There were no pertinent physical findings, complications, conditions, signs, or symptoms related to the Veteran’s condition. He had a surgical scar related to the hernia. However, the scar was not painful and/or unstable, or have a total area equal or greater than 39 square cm (6 square inches) or located on the head, face, or neck. There were no significant diagnostic findings. Based on the evidence of record, the Board finds that a compensable rating for residuals of hernia is not warranted. Pursuant to DC 7338, a compensable rating for a postoperative inguinal hernia requires recurrence of the hernia, which has not occurred in this case. There is no doubt to be resolved; the assignment of a compensable rating pursuant to DC 7338 is not warranted. The Board has considered whether a higher or separate rating is warranted under another DC. The Board finds that a separate 10 percent rating is warranted for the Veteran’s scar, status post hernia surgery. The VA examiners noted that the Veteran had a surgical scar related to his hernia. Additionally, a June 2017 VA scar examination noted that the Veteran had a linear scar on his anterior trunk that was due to his hernia surgery. The scar did not affect his head, face, neck, posterior trunk, or upper or lower extremities. The scar was not due to burns. He did not have superficial non-linear or deep non-linear scars. The Veteran’s scar did not result in limitation of function. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms (such as muscle or nerve damage) associated with any scar or disfigurement. The VA examiners all noted that the scar was not painful, or unstable, with frequent loss of covering of skin over the scar. However, the Board notes that during his 2015 VA examination, the Veteran stated that he experienced pain around the surgical site. The Veteran is competent to relate this symptom of his own illness, see Layno v. Brown, 6 Vet. App. 465, 470 (1994), and the Board finds him to be credible in this regard because his treatment records also note complaints of pain related to his hernia. Therefore, resolving reasonable doubt in the Veteran’s favor, the Board finds that a separate rating under DC 7804 is warranted for the Veteran’s scar. The Board assigns a 10 percent rating for one or two scars that are painful. A higher rating is not available unless there is evidence of three or four scars that are painful. The Board acknowledges the Veteran and his representative’s statements regarding the Veteran’s hernia to be both competent and credible. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the VA examiners’ opinions or the evidence of record on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the Board finds that the lay opinions by themselves are outweighed by the VA examiners’ findings. Accordingly, the preponderance of the evidence is against a compensable disability rating for the Veteran’s hernia. 38 C.F.R. § 4.3. 3. Entitlement to a compensable rating for urethritis The Veteran urethritis is rated under 38 C.F.R. § 4.115b, DC 7525, for epididymo-orchitis, chronic, which is rated as urinary tract infection. Urinary tract infections requiring long-term drug therapy, one to two hospitalizations a year and/or requiring intermittent intensive management are rated as 10 percent disabling. Recurrent symptomatic infections requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management are rated as 30 percent disabling. Infections resulting in poor renal function are to be rated as renal dysfunction. 38 C.F.R. § 4.115a. Diagnostic Code 7525 also provides that for tubercular infections, rate in accordance with 38 C.F.R. §§ 4.88b or 4.89, whichever is appropriate. However, since there has been no objective evidence of tubercular infections in this case, this section is inapplicable. Analysis The Veteran contends that his urethritis is more severe than the noncompensable rating depicts. In June 2017, the Veteran was afforded a VA examination to determine the severity of the Veteran’s urethritis. The examiner performed an in-person examination. The Veteran stated that in 2005 when he was treated for chlamydia, he was also diagnosed with urethritis. The examiner confirmed the Veteran’s urethritis diagnosis. However, the condition had resolved. The Veteran did not have voiding dysfunction. Additionally, he did not have a history of urethral, bladder calculi, recurrent symptomatic bladder, or urethral infections. The Veteran did not have a bladder injury or surgery or renal dysfunction due to his condition. There were no findings, signs, or symptoms attributable to a bladder or urethral fistula, or neurogenic or a severely dysfunctional bladder. There were no other pertinent physical findings, complications, conditions, signs, symptoms, or scars related to the Veteran’s condition. Based on the evidence of record, the Board finds that a compensable rating is not warranted. There is no evidence to show that the Veteran has a history of urinary tract infection. The June 2017 VA examiner noted that the Veteran’s condition had resolved. Therefore, the Board finds that the evidence is insufficient to show that the required criteria have been met. Therefore, a compensable rating under DC 7525 is not warranted. The Board has also considered whether a compensable rating is warranted under any other diagnostic code. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). However, the Veteran did not have voiding dysfunction. Additionally, he did not have a history of urethral or bladder calculi or recurrent symptomatic bladder or urethral infections. The Veteran did not have a scar, bladder injury, bladder surgery, or renal dysfunction due to the condition. Additionally, there is no evidence to show that the Veteran has complete atrophy, or removal, of both testes. 38 C.F.R. § 4.115b, DCs 7515-17, 7517, 7523-7524, 7800. The Board acknowledges the Veteran and his representative’s statements regarding the severity of the Veteran’s urethritis. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the VA examiner’s opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the Board finds that the lay opinions by themselves are outweighed by the VA examiner’s findings and the other evidence of record. Accordingly, the preponderance of the evidence is against compensable rating for the Veteran’s urethritis. 38 C.F.R. § 4.3. 4. Entitlement to a rating in excess of 10 percent for chronic low back pain The Veteran’s back disability is rated under 38 C.F.R. § 4.71a, 5235-5243 according to a General Rating Formula for Disease and Injuries of the Spine (General Formula) unless DC 5243 is evaluated under the Formula for Rating IVDS based on incapacitating episodes (IVDS Formula). For purposes of evaluations under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Schedular disability ratings are assigned for the spine from 100 percent to 10 percent according to the formulas as follows: Under the General Formula, a 10 percent rating contemplates forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating contemplates forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion (ROM) of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Alternatively, under the IVDS Formula, a 20 percent rating contemplates incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating contemplates forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Under the IVDS Formula, a 40 percent rating contemplates incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 50 percent rating contemplates unfavorable ankylosis of the entire thoracolumbar spine. There is no equivalent rating under the IVDS Formula. Under the IVDS Formula, a 60 percent rating contemplates incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. There is no equivalent rating under the General Formula. A 100 percent rating contemplates unfavorable ankylosis of the entire spine. There is no equivalent rating under the IVDS Formula. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of “the normal working movements of the body,” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Associated objective neurologic abnormalities are evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a (General Formula, Note 1). Analysis The Veteran contends that his low back condition is more severe than the 10 percent rating depicts. In March 2015, the Veteran was afforded a VA examination to determine the severity of his low back disability. The examiner reviewed the Veteran’s claims file and performed an in-person examination. The Veteran stated that in 2006, he gradually experienced pain affecting the lower back with heavy lifting and carry. He reported treatment to include physical therapy and anti-inflammatory medication. The examiner confirmed the Veteran’s mechanical back pain syndrome and lumbosacral strain/strain diagnoses. The Veteran reported periodic flare-ups and functional loss or impairment which limited functionally with continuous activities requiring running, heaving lifting, bending, squatting, hiking, or jumping. The Veteran’s range of motion (ROM) was all normal, i.e., forward flexion was to 90 degrees and extension, right and left lateral flexion, and left and right lateral rotation were all to 30 degrees. The Veteran was able to perform repetitive-use testing with no change in ROM after repetitive-use testing. The Veteran experienced pain on active, passive, and/or repetitive ROM. The pain contributed to functional loss or additional limitation of ROM. The Veteran also experienced pain on weight bearing or non-weight-bearing. The pain contributed to function loss or additional limitation of ROM. The was no functional loss during flare-ups or when the joint was used repeatedly over a period of time. The Veteran experienced localized mild tenderness or pain on palpation along the paravertebral muscles. The Veteran had guarding or muscle spasm of the spine. However, his gait and spinal contour were normal. Contributing factors of the disability included pain on movement; however, the pain was not associated with limitation of motion. Additionally, neither pain, weakness, fatigability, nor incoordination significantly limited functional ability during flare-ups or when the joint was used repeatedly over time. The Veteran did not experience any functional loss during flare-ups or when the joint was used repeatedly over time. His muscle strength was normal with no muscle atrophy. His reflex and sensory exams were also normal. Straight leg raising test was negative, and he did not have radicular pain or any other subjective symptoms due to radiculopathy. The Veteran did not experience ankylosis, IVDS, or other neurologic abnormalities or findings related to his low back disability. The Veteran did not use an assistive device as a normal mode of locomotion. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings, complications, conditions, signs or symptoms, or any scars related to the Veteran’s back condition. From August 2015, the Veteran’s treatment records note complaints and treatment for painful back. In May 2016, the Veteran was afforded a VA examination to determine the severity of his low back condition. The examiner reviewed the Veteran’s claim file and performed an in-person examination. The Veteran stated that since the last rating, his back had gotten worse. He stated that he had daily back pain, and he had to pop his back on a regular basis. He stated that his back/tailbone was “killing him” while he sat. He stated that he wore a back brace that did not work. He also used a cane as a means of locomotion. He denied any incontinence or any pain radiation. The examiner confirmed the Veteran’s lumbosacral strain and/or chronic low back pain to include back spasms diagnoses. The Veteran did not report flare-ups. He reported having functional loss or impairment due to his back pain. He stated that due to back pain, he could not bend, sit, and carry. The Veteran’s ROM was all normal, i.e., forward flexion was to 90 degrees and extension, right and left lateral flexion, and left and right lateral rotation were all to 30 degrees. The Veteran experienced pain on forward flexion, extension, right and left lateral flexion and right and left lateral rotation, but the pain did not result in/cause functional loss. The Veteran also experienced pain on weight bearing, and there was objective evidence of localized moderate tenderness or pain on palpation along his lower back. The Veteran was able to perform repetitive-use testing with at least three repetitions. There was no change in ROM after repetitive testing. The Veteran was not examined immediately after repetitive use over time; therefore, the examiner noted that the examination was neither medically consistent or inconsistent with the Veteran’s statement describing functional loss with repetitive use over time. Pain and fatigue significantly limited functional ability with repeated use over a period of time. After repetitive use over time, forward flexion was to 85 degrees and extension, right and left lateral flexion, and left and right lateral rotation were all to 25 degrees. The examination was not conducted during a flare-up and the examination was neither medically consistent or inconsistent with the Veteran’s statement describing functional loss during flare-ups. Additionally, neither pain, weakness, fatigability, nor incoordination significantly limited functional with flare-ups. The Veteran experienced guarding or muscle spasms of the spine, and localized tenderness; however, they did not result in abnormal gait or abnormal spinal contour. There were no other factors contributing to the disability. The Veteran’s muscle strength testing was normal with no muscle atrophy. His reflex and sensory exams were normal. Straight leg raising test was negative, and he did not have radicular pain or any other subjective symptoms due to radiculopathy. The Veteran did not experience ankylosis, IVDS or other neurologic abnormalities or findings related to his low back disability (such as bowel or bladder problems/pathologic reflexes). Occasionally, the Veteran used a cane and braces as assistive devices. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings, complications, conditions, signs or symptoms, or any scars related to the Veteran’s back condition. Diagnostic testing did not reveal arthritis or thoracic vertebral fracture with loss of 50 percent or more of height. Diagnostic testing revealed a normal lumbar spine. In June 2017, the Veteran was afforded a VA examination to determine the severity of the Veteran’s chronic low back disability. The examiner performed an in-service examination. The Veteran stated that his low back pain symptoms began in 2005. Since then, the condition has gotten worse. The examiner confirmed the Veteran’s chronic low back pain diagnosis. The Veteran reported flare-ups, to include pain, stiffness, and decreased ROM. He did not report functional loss or functional impairment. The Veteran’s ROM was normal, i.e., forward flexion was from zero to 90 degrees and extension, right and left lateral flexion, and left and right lateral rotation were all from zero to 30 degrees. There was no pain noted on the exam. Additionally, there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the back. The Veteran able to perform repetitive-use testing with at least three repetitions; however, there was no loss of function or ROM after three repetitions. The examiner stated that passive ROM testing was not performed as it was not medically appropriate. There was no evidence of pain on non-weight bearing testing of the back. The Veteran was examined immediately after repetitive use over time. The examiner noted that neither pain, weakness, fatigability, nor incoordination significantly limited functional ability with repeated use over a period of time. The examination was not conducted during a flare-up; therefore, the examiner stated that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss during flare up. Neither pain, weakness, fatigability nor incoordination significantly limited functional ability with flare ups. The Veteran did not experience localized tenderness, guarding, or muscle spasms. There were no additional contributing factors to the disability. The Veteran’s muscle strength was normal with no muscle atrophy. The Veteran’s reflex and sensory exams were also normal. Straight leg testing was negative, and he did not have radicular pain or any other subjective symptoms due to radiculopathy. The Veteran did not experience ankylosis, IVDS, or other neurologic abnormalities or findings related to his low back disability. The Veteran did not use an assistive device as a normal means of locomotion. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings, complications, conditions, signs or symptoms, or any scars related to the Veteran’s back condition. The examiner stated that the Veteran had a normal back examination. Based on the evidence of record, the Board finds that a rating in excess of 10 percent for the Veteran’s low back pain is not warranted. Given the medical evidence of record, the Board finds that the Veteran’s low back pain has not been more nearly manifested by forward flexion greater than 30 degrees but not greater than 60 degrees. At worse, the Veteran’s forward flexion was to 85 degrees. The Board notes that the March 2015 and the May 2016 VA examiners noted that the Veteran had spasms of the spine. However, the examiners also noted that the spasms did not result in abnormal gait and spinal contour was normal. Additionally, the Veteran’s disability did not result in incapacitating episodes of IVDS having a total duration of at least 2 weeks but less than 4 weeks during the last 12 months. The Board has also considered the effect of pain, weakness, fatigability, or incoordination in evaluating the Veteran’s disability. DeLuca, 8 Vet. App. 202; 38 C.F.R. §§ 4.40, 4.45, 4.59. The Board notes that the Veteran had some functional loss/impairment which limited functionally with continuous activities requiring running, heaving lifting, bending, squatting, hiking, or jumping. Functional loss also included pain on movement. Although the Veteran experienced additional functional limitation, the loss in ROM is not commensurate with that for the next higher rating. Additionally, such functional impairment has been considered in arriving at the current rating for limitation of motion of the lumbar spine based on ROM measurements, to include as due to objective evidence of pain and subjective complaints of painful motion resulting in the functional impairment described above. See 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, 8 Vet. App. 206-07 (1995). The Board has considered whether separate ratings are warranted for other neurologic abnormalities. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). However, the evidence does not show any objective neurologic abnormalities associated with the Veteran’s back disability. The Board has considered the Veteran and his representative’s statements regarding the severity of the Veteran’s back disability. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the VA examiners’ opinions on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions by themselves are outweighed by the VA examiners’ findings and other evidence of record. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court’s conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert’s opinion more probative on the issue of medical causation). Therefore, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s disability picture more nearly approximates a rating in excess of 10 percent. 5. Entitlement to a rating in excess of 10 percent for bilateral knee patellar tendonitis. The Veteran’s bilateral knee condition is currently assigned a 10 percent rating under 38 C.F.R. § 4.71a, DC 5024-5257. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional DCs to identify the specific basis for the evaluation assigned. 38 C.F.R. § 4.27. In this case, DC 5024 refers to tenosynovitis. Under DC 5024, the disability is rated on limitation of motion of the affected part or as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5024. Diagnostic code 5260 is used to denote the rating criteria for the limitation of flexion of the leg. 38 C.F.R. § 4.71a. Limitation of flexion is rated as follows: flexion limited to 60 degrees warrants a noncompensable rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to 15 degrees warrants a 30 percent rating. See 38 C.F.R. § 4.71a, DC 5260. Diagnostic Code 5261 evaluates limitation of extension as follows: extension limited to 5 degrees warrants a noncompensable rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 30 degrees warrants a 40 percent rating; and extension limited to 45 degrees warrants a 50 percent rating. See 38 C.F.R. § 4.71a, DC 5261. The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic code 5257 is used to evaluate recurrent subluxation or lateral instability of the knee. Severe symptoms warrant a 30 percent rating; and slight symptoms warrant a 10 percent rating. See 38 C.F.R. § 4.71a, DC 5257. The terms “slight,” “moderate,” and “severe” are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence to arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (DC 5260), limitation of extension (DC 5261), lateral instability or recurrent subluxation (DC 5257), and meniscal conditions (DCs 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of “the normal working movements of the body,” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Associated objective neurologic abnormalities are evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a (General Formula, Note 1). Analysis The Veteran contends that his bilateral knee condition is more severe than the 10 percent rating depicts. In March 2015, the Veteran was afforded a VA examination to determine the severity of his bilateral knee disability. The examiner reviewed the Veteran’s claims file and performed an in-person examination. The examiner confirmed the Veteran’s bilateral knee patellar tendonitis. The Veteran reported functional loss or impairment of the joint, periodic flare-ups, and limited functionally with continuous activities requiring running, heavy lifting, bending, squatting, hiking, or jumping. The Veteran’s bilateral ROM was normal, i.e., forward flexion from zero to 140 degrees and extension from 140 to zero degrees. Bilaterally, the Veteran experienced pain on flexion which did not result in or cause functional loss. There was no crepitus or pain on weight bearing. There was objective evidence of localized mild tenderness or pain on palpation of the bilateral patella tendon. The Veteran was able to perform repetitive-use testing with no change in ROM. He was not examined immediately after repetitive use over time; therefore, the examiner noted that the examination neither supports nor contradicts the Veteran’s statement describing functional loss with repetitive use over time. The Veteran’s bilateral ROM remained the same. The Veteran reported mild flare-ups once or twice per week for 20 to 30 minutes. However, the examination was not conducted after a flare-up; therefore, the examiner stated that the examination neither supported nor contradicted the Veteran’s statements describing functional loss during flare-ups. The examiner stated that neither pain, weakness, fatigability, nor incoordination significantly limited functional ability during flare-ups or when the joint was used repeatedly over time. The Veteran’s bilateral ROM remained the same. The examiner noted that pain on movement was a contributing factor of the disability. The Veteran’s muscle strength was normal with no reduction in muscle strength or muscle atrophy. There was no joint instability. The Veteran did not experience ankylosis. He did not have a history of recurrent subluxation, lateral instability, or recurrent effusion. The Veteran did not now have or has ever had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. He also did not have a meniscus (semilunar cartilage) condition, total knee replacement, or scars related to his bilateral knee condition. The Veteran did not use an assistive device as a normal mode of locomotion. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the Veteran’s bilateral knee condition. In May 2016, the Veteran was afforded a VA examination to determine the severity of his low back condition. The examiner reviewed the Veteran’s claim file and performed an in-person examination. The Veteran stated that since the last rating decision, both knees have given out. While at rest, there was stiffness and throbbing of the knees. He used three braces for the knees. Sometimes, he experienced knee swelling. He was unable to run. The examiner confirmed the Veteran’s bilateral knee patellar tendonitis diagnosis. The Veteran did not report flare-ups; however, he experienced functional loss or impairment of the knees. The Veteran stated that standing, bending, and picking things up were limited due to his knee. The Veteran’s ROM was abnormal. Right knee forward flexion was to 140 degrees and extension to zero degrees. The Veteran experienced right knee pain on flexion and extension, but the pain did not result in /cause functional loss. There was experienced pain on weight bearing and objective evidence of localized moderate tenderness or pain on palpation along the tender distal patellar tendon. There was no objective evidence of crepitus. Left knee flexion was to 110 degrees and extension to zero. The Veteran experienced left knee pain on flexion and extension that caused functional loss, to include limiting the Veteran’s ability to kneel and run. There was evidence of pain on weight bearing and objective evidence of localized moderate tenderness or pain on palpation along the tender distal patellar tendon. There was no objective evidence of crepitus. Bilaterally, the Veteran was able to perform repetitive-use testing with at least three repetitions with no change in ROM. The Veteran was not examined immediately repetitive use over time; therefore, the examiner noted that the examination neither supports nor contradicts the Veteran’s statement describing functional loss with repetitive use over time. Bilateral pain and fatigability significantly limited functional ability with repeated use over time. After repetitive-use testing, right knee forward flexion was to 135 degrees and extension to zero. Left knee forward flexion was to 105 degrees and extension to zero. The examination was not conducted during a flare-up; therefore, the examiner stated that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss during flare-ups. Neither pain, weakness, fatigability, nor incoordination significantly limited functional ability with flare-ups to either knee. The examiner noted no functional loss for the right lower extremities that was attributed to the knee condition. The Veteran experienced less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-ups, contracted scars, etc.) of the left knee. His muscle strength was normal with no muscle atrophy or reduction in muscle strength. The Veteran did not experience ankylosis. He did not have a history of recurrent subluxation, lateral instability, or recurrent effusion. There was no joint instability. The Veteran did not now have or has ever had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The Veteran did not now have or had ever had a meniscus (semilunar cartilage) condition. There were no scars related to the Veteran’s condition. He used braces as a normal mode of locomotion. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. X-rays revealed intact osseous structures. There was also no evidence of joint space of soft tissue abnormality or traumatic arthritis. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms related to his bilateral knee condition. In June 2017, the Veteran was afforded a VA examination to determine the severity of his bilateral knee condition. The examiner performed an in-person examination. The Veteran stated that his bilateral knee condition began in 2006 secondary to running and cumulative trauma. He stated that the condition has gotten worse. The examiner confirmed the Veteran’s bilateral patellar tendonitis diagnosis. However, the condition was quiescent. The Veteran reported flare-ups which included bilateral knee pain which was worse with prolonged standing and walking. The Veteran did not report functional loss or impairment of the knee. The Veteran’s bilateral ROM was all normal, i.e., forward flexion was from zero to 140 degrees and extension was from 140 to zero degrees. There was no pain on the exam. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was also no objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions; however, there was no additional loss of function or ROM after three repetitions. He was examined immediately after repetitive use over time. The examination was not conducted during a flare up; therefore, the examiner stated that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss during flare up. Neither pain, weakness, fatigability nor incoordination significantly limit functional ability with flare-ups or with repeated use over a period of time. Correia joint testing was performed with no evidence of pain on passive ROM testing and no evidence of pain in non-weight-bearing, bilaterally. There were no additional contributing factors of the disability. The Veteran’s muscle strength was normal with no muscle atrophy. He did not experience ankylosis. The Veteran did not have a history of recurrent subluxation, lateral instability, or recurrent effusion. The Veteran’s did not experience joint instability. He did not now have or has ever had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The Veteran did not now have or had ever had a meniscus (semilunar cartilage) condition. The Veteran did not have any scars related to his bilateral knee condition. He did not use an assistive device as a normal mode of locomotion. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the Veteran’s bilateral knee conditions. Based on the evidence of record, the Board finds that a rating in excess of 10 percent for the Veteran’s bilateral knee condition is not warranted. There is no evidence that the Veteran has had limitation of bilateral knee flexion to 30 degrees or less or that he had limitation of extension to 15 degrees or more. The record shows that at worse, the Veteran right and left knee flexion was to no less than 135 and 105 degrees, respectively. The criteria for a disability rating higher than 10 percent under DC 5260 is not met. The Board also notes that the Veteran has normal extension, bilaterally; therefore, a separate rating under 5261 is not warranted. The Board recognizes that, under DeLuca v. Brown, 8 Vet. App. 202 (1995), VA must consider “functional loss” of a musculoskeletal disability separately from consideration under the DCs. The Veteran experienced functional loss which limited functionally with continuous activities requiring running, heavy lifting, bending, squatting, hiking, or jumping. However, the Board finds that given the extent of bilateral knee motion and the extent of functional and occupational impairment indicated in the record, the evidence does not support a disability picture that establishes entitlement to a higher disability rating, even after taking his reported pain into full consideration. See DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5260 and 5261. Further, the Board has considered the potential application of the other provisions of 38 C.F.R., Parts 3 and 4. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Board notes that other criteria for rating knee disabilities are provided under DCs 5256 (for ankylosis), and 5262 (for impairment of the tibia and fibula). The evidence does not show that the Veteran’s bilateral knee disability manifestations have included ankylosis or impairment of the tibia and fibula. In the absence of such manifestations, those DCs are inapplicable in this case. Additionally, the Veteran did not experience instability or meniscus tear. Therefore, a separate rating is not warranted under DC 5258 (for recurrent subluxation or lateral instability) or 5258 (for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion). Additionally, 5259 (for symptomatic removal of the semilunar cartilage) is inapplicable in this case. The Board has considered the Veteran and his representative’s statements regarding the severity of the Veteran’s bilateral knee condition. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the VA examiners’ opinions on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions by themselves are outweighed by the VA examiner’s findings and the other evidence of record. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court’s conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert’s opinion more probative on the issue of medical causation). Therefore, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s bilateral knee disability picture more nearly approximates a rating in excess of 10 percent. 6. Entitlement to a rating in excess of 50 percent for chronic sinusitis status post septoplasty The Veteran’s sinusitis is rated under Diagnostic Code 6512, all forms of sinusitis are evaluated under the General Formula for Sinusitis (DC’s 6510 through 6514). A 50-percent rating is appropriate following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 38 C.F.R. § 4.97, DC 6512. Analysis The Veteran contends that his sinusitis is more severe than the 50 percent rating depicts. In March 2015, the Veteran was afforded a VA examination to determine the severity of his disabilities. The examiner reviewed the Veteran’s claims file and performed an in-person examination. The Veteran began experiencing multiple episodes of nasal congestion accompanied drainage. The Veteran took antihistamines and periodically used nasal rinsing with improvements. The examiner confirmed the Veteran’s chronic sinusitis diagnosis. The Veteran’s chronic and/or recurrent sinusitis affected his frontal, ethmoid, sphenoid, and pansinusitis. He had findings, signs, or symptoms attributable to chronic sinusitis to include episodes of sinusitis, near constant sinusitis, headaches, and pain and tenderness of the affected sinus. The Veteran did not have non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting in the past 12 months nor did he have incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotics in the past 12 months. The Veteran had sinus surgery, i.e., septoplasty; however, he did not have radical sinus surgery followed by chronic osteomyelitis. He did not have allergic, vasomotor, bacterial, or granulomatous rhinitis. Additionally, he did not have chronic laryngitis, laryngectomy, aphonia, laryngeal stenosis, pharyngeal injury or any other pharyngeal conditions. He did not have a deviated nasal septum due to trauma or a benign or malignant neoplasm or metastases related to his sinusitis. The Veteran did not have any scars related to his condition. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the Veteran’s sinusitis condition. In May 2016, the Veteran was afforded a VA examination to determine the severity of his sinusitis. The examiner reviewed the Veteran’s claim file and performed an in-person examination. The Veteran stated that since the last rating, his condition remained the same. He stated that he always felt clogged up, and he unable to hear his words clearly. Additionally, he stated that when he breathed in, it felt like his left nostril would collapses. If he had a cold, or if his throat swells up, his breathing problems became worse. Swallowing also became difficult. He denied any exposure or triggers. He stated that symptoms occurred year-round and nasals sprays did not work. The examiner confirmed the Veteran’s chronic sinusitis, status post septoplasty. The chronic sinusitis affected the Veteran’s frontal and ethmoid sinuses. There were findings, signs, or symptoms attributable to chronic sinusitis, to include chronic nasal congestion with drainage. Congested mucosa was also noted. The Veteran also experienced headaches. The Veteran did not have non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting in the past 12 months nor did he have incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotics in the past 12 months. The Veteran had sinus surgery, i.e., septoplasty; however, he did not have radical sinus surgery followed by chronic osteomyelitis. The Veteran did not have any scars related to his condition. The Veteran did not have loss of part of the nose or other scars of the nose exposing both nasal passages, loss of part of the nose or other scars causing loss of part of one ALA, or loss of part of the nose or other scars causing any other disfigurement. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the Veteran’s condition. In June 2017, the Veteran was afforded a VA examination to determine the severity of his sinusitis. The examiner performed an in-person examination. The Veteran stated that his condition began in 2005 when he had a septoplasty procedure. Since onset, the condition has gotten worse. The examiner confirmed the Veteran’s chronic sinusitis, status post septoplasty. However, the condition was quiescent. The Veteran did not have any scars related to his condition. He did not have loss of part of the nose or other scars of the nose exposing both nasal passages or loss of part of the nose or other scars causing loss of part of one ALA, or loss of part of the nose or other scars causing any other disfigurement. There were no clinical findings on the sinus x-rays. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms related to the Veteran’s condition. The examiner stated that the examination unremarkable. There were no acute or chronic signs of sinusitis on physical examination. The Board notes that the Veteran is in receipt of the highest rating available under DC 6512. The Board has considered whether separate and/or higher disability ratings are warranted under any other potentially applicable DCs pertaining to diseases of the ear, nose, and throat. The 2015 VA examiner noted that the Veteran did not have a deviated septum or loss of part of nose or scars relate to his condition. Therefore, a higher and/or separate rating is not warranted under DCs 6502 and 6504. Additionally, he did not have chronic laryngitis, laryngectomy, aphonia, laryngeal stenosis, pharyngeal injury or any other pharyngeal conditions and/or rhinitis that was allergic, vasomotor, bacterial, or granulomatous. Therefore, a higher and/or separate rating is not warranted under DCs 6515-6523. The Board has considered the Veteran and his representative’s statements regarding the severity of the Veteran’s sinusitis. However, as lay persons, the Veteran and his representative do not have the training or expertise to render a competent opinion which is more probative than the VA examiners’ opinions on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions by themselves are outweighed by the VA examiners’ findings. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court’s conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert’s opinion more probative on the issue of medical causation). Therefore, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s disability picture more nearly approximates a rating in excess of 50 percent. 7. Entitlement to TDIU Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation because of service-connected disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). “Substantially gainful employment” is employment “which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides.” Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). “Marginal employment shall not be considered substantially gainful employment.” 38 C.F.R. § 4.16(a). In determining whether unemployability exists, consideration may be given to the veteran’s level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Analysis The Veteran contends that his service-connected disabilities precludes him from securing or following substantially gainful employment. A review of the procedural history reflects that the issue of entitlement to TDIU originated from a September 8, 2015 claim. As such, the period relevant to the appeal begins on that date. From September 8, 2015, the Veteran was service connected for chronic sinusitis rated at 50 percent effective January 12, 2015; insomnia rated at 30 percent effective January 12, 2015; right and left knee patellar tendonitis and chronic low back pain each rated at 10 percent effective from January 12, 2009; and residuals of hernia surgery and urethritis with a noncompensable rating effective June 28, 2009. From January 12, 2015, the Veteran’s overall rating was 80 percent. The Veteran met the threshold requirement for TDIU. 38 C.F.R. § 4.16(a). According to the Veteran’s form 21-8940, Application for Compensation based Unemployability, the Veteran completed two years of college. After service, he worked at a warehouse. Before becoming too disabled to work, he received training as a truck driver and obtained a forklift certification. In November 2015 and March 2016, the Social Security Administration (SSA) denied the Veteran’s claim for disability. In 2016, the examiner affirmed the 2015 denial. On his SSA application, the Veteran stated that he took care of his wife as she was disabled with a very bad back problem. Depending on the meals, the Veteran stated that he helped his wife prepared meals either on a daily or weekly basis. He cleaned, did laundry, and small house things also on a daily or weekly basis. The Veteran was able to walk, use public transportation, and ride a bike. He stated that he was able to shop in stores and online. He paid his own bills, handled a savings account and counted change. The SSA examiner stated that the Veteran’s impairment or combination of impairments to include hernia with surgery, chronic low back pain with back spasms, bilateral knee patellar tendonitis, adenoiditis septoplasty tube reduction, breathing disorder, arthritis of both hands, depression, anxiety, sleeping problems, bilateral hearing loss, and neck pain did not significantly limit the Veteran’s physical or mental ability to do basic work activities. Regarding if the Veteran was able to perform past relevant work, the examiner stated that that determination had not been made. The examiner further stated that the information was not material because all potentially applicable medical-vocational guidelines would direct a finding of “not disabled” given the individual’s age, education, and RFC. Therefore, “the individual can adjust to other work.” In March 2015, the Veteran was afforded VA examinations to determine the severity of his disabilities. The examiner noted that the Veteran’s hernia was did not have an impact on his ability to work. Regarding his back and bilateral knee conditions, the examiner stated that the conditions had an impact on his employment. The examiner noted that the Veteran had limited functionality with continuous activities requiring running, heavy lifting, bending, squatting, hiking, or jumping. However, the Veteran can perform any type of occupational task without significant restrictions. In August 2015, the Veteran was seen at the Loma Linda HCS: Mental Health Note. The Veteran stated that he worked in warehouse “probably worked for a month.” The examiner stated that from what she understood, the Veteran felt he was underpaid for the number of days he worked and tired of walking three miles each way to work. In May 2016, the Veteran was afforded VA examinations to determine the severity of his service-connected disabilities and if his service-connected disabilities rendered him unemployable. The Veteran’s back and bilateral knee conditions, the examiner noted that they had an impact on his employment; however, the examiner noted that the Veteran can perform any type of occupational task without significant restrictions. Walking and standing for prolonged periods of time were limited. Additionally, the Veteran was limited with prolonged crouching, kneeling, bending, stooping, lifting and carrying, and overhead lifting of heavy loads. However, the examiner stated that the Veteran can entertain moderate to light physical and sedentary employment. The examiner noted that the Veteran’s sinusitis had an impact on the Veteran’s ability to work. The Veteran was able to perform general activities without significant restrictions and was able to perform most activities. The examiner stated that the Veteran was not functionally impaired as it related to the sinusitis diagnosis and can perform both physical and sedentary employment. In October 2016, the Veteran submitted a statement from a certified rehabilitation counselor. The examiner reviewed the Veteran’s claims file and spoke to the Veteran via telephone. However, the examiner did not perform an in-person examination. The examiner opined that it is more likely than not that the Veteran’s combined service-connected disabilities prevented him from securing and following substantially gainful employment since 2013 when he last worked. The Veteran stated that he attended college for three years majoring in computer information technology. In 2015, the Veteran attempted to returned to work but due to his disabilities, he was forced to quit. The Veteran stated that his back and knee injuries prevented him from standing or walking for long periods. He also had difficulty bending over. Due to his problems with breathing, the Veteran noted that he broke into sweat and hives which resulted in headaches, and this impacted his ability to focus and concentrate. The examiner stated that although the Veteran obtained some skills from three years of college, the Veteran’s sinusitis with associated insomnia impacted his ability to secure and sustain full-time gainful and substantial employment, even at the sedentary work classification level. The examiner concluded that the combined service-connected disabilities prevent the Veteran from securing and following substantially gainful employment since 2013. The Veteran’s VA treatment record notes that in January 2017, the Veteran stated that he exercised/ran three or four miles every other day. In June 2017, the Veteran was afforded VA examinations to determine the severity of his disabilities. A VA examiner noted that the Veteran’s insomnia caused poor concentration with related memory problems due to sleep disturbance. This affected the Veteran’s functional impairments. Regarding his back condition, the examination did not reveal physical impairments that would significantly preclude the claimant from maintaining gainful employment. The Veteran can participate and function in almost any activity of employment as tolerated. The examiner stated that neither the Veteran’s hernia, scar, sinusitis, nor urethritis had an impact on his ability to work. The Veteran hernia and urethritis had resolved and his sinusitis was inactive. The examiner stated that the Veteran urethritis examination did not reveal physical impairments that would significantly preclude the Veteran from maintaining gainful employment. He can participate and function in almost any activity of employment as tolerated. The examiner noted that the Veteran’s bilateral knee disability did not have an impact on his ability to perform any type of occupational task. Physical examination did not reveal physical impairments that would significantly preclude the Veteran from maintaining gainful employment. He can participate and function in almost any activity of employment as tolerated. Based on the evidence of records, the Board finds that during the periods on appeal, the Veteran’s disabilities did not preclude him from all forms of employment. The Board notes that in October 2016, the Veteran submitted a statement asserting that his combined service-connected disabilities prevented him from securing and following substantially gainful employment since 2013. The examiner stated that although the Veteran obtained some skills from three years of college, the Veteran’s sinusitis with associated insomnia impacted his ability to secure and sustain full-time gainful and substantial employment, even at the sedentary work classification level. However, on his SSA application, the Veteran stated that he was able to perform activities, to include helping prepare meals, cleaning, doing laundry, and performing small house chores. These activities were performed either on a daily or weekly basis. The Veteran walked, used public transportation, and rode a bike. He shopped online using a computer and was able to manage his own finances. In January 2017, the Veteran stated that he exercised or ran three to four miles every other day. As such, the Board finds the opinion to be less probative than other medical evidence of record, as the examiner’s conclusion is inconsistent with the evidence of record, to include the Veteran’s statements. On the other hand, the VA examiners noted the Veteran’s medical history from either soliciting the history directly from the Veteran and/or from the claims file, examined the Veteran, and provided an articulated opinion. The Board therefore attaches significant probative value to the VA examiners’ opinions, and the most probative value in this case, as the examinations were detailed, consistent with other evidence of record, and included history of the Veteran’s disabilities. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board also notes that in his July 2017 Correspondence, the Veteran, through his representative stated that the June 2017 examination was inadequate because the examiner opined on each condition separately when discussing the Veteran’s unemployability. Additionally, the Veteran stated that the 2017 doctor noted that no records were reviewed for these exams. However, based on the totality of the evidence, the Board finds that the Veteran is not entitled to TDIU or another examination. The Board notes that no VA examiner, to include the 2015 and 2016 examiners, have stated that the Veteran was unemployable due to his service-connected disabilities. The 2015 examiner stated that the Veteran had limited functionality with continuous activities requiring running, heavy lifting, bending, squatting, hiking, or jumping. However, the Veteran can perform any type of occupational task without significant restrictions. The 2016 examiner stated that even with the disabilities, the Veteran was able to entertain moderate to light physical and sedentary employment with limitations. The Veteran was able to perform general activities without significant restrictions and was able to perform most activities. The 2017 examiner stated that the physical examinations did not reveal physical impairments that would significantly preclude the claimant from maintaining gainful employment. He can participate and function in almost any activity of employment as tolerated. Additionally, based on the combination of the Veteran’s impairments, SSA determined that the Veteran’s combined disabilities did not significantly limit physical or mental ability to do basic work activities. The SSA examiner also noted that all potentially applicable medical-vocational guidelines would direct a finding of “not disabled” given the individual’s age, education, and RFC. Therefore, “the individual can adjust to other work.” Therefore, based on the Veteran’s occupational and educational history to include two to three years of college courses majoring in computer information technology along with his statements regarding his ability to perform daily tasks, the Board finds that, at a minimum, the Veteran is able to perform sedentary work. Therefore, the objective evidence of record does not support a finding that the Veteran’s service-connected disabilities, when considered along with his educational and occupational history, prevents him from securing or following any type of substantially gainful employment. The Board has acknowledged and considered the Veteran and his representative’s statements addressing his employability. The Board notes that the Veteran is competent and credible to report the subjective symptoms and functional limitations he experiences regarding his service-connected disabilities. See Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Nonetheless, the Board emphasizes that the Veteran’s description of his service-connected disabilities must be considered in conjunction with the clinical evidence of record, as well as the pertinent rating criteria. While the Board does not doubt that the Veteran’s disabilities have a significant effect on his employability, the weight of the evidence does not support his contention that his service-connected disabilities are of such severity to preclude his participation in any form of substantially gainful employment based on his occupational background and level of education. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 C.F.R. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Henry, Associate Counsel