Citation Nr: 18151132 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 12-10 119 DATE: November 16, 2018 ORDER Service connection for a right forearm disability is denied. Service connection for a right ankle disability is denied. Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. A total disability based on individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. The Veteran had a right forearm injury when he entered service, and it was not aggravated by service. 2. The Veteran has a right ankle disability, but he did not incur or aggravate a right ankle injury or disease during service. 3. The Veteran has a right knee disability, but it is not related to his incurring or aggravating a right knee injury or disease during service. 4. The Veteran has a left knee disability, but it cannot be service-connected as secondary to a right knee disability because he is not service connected for such and it is not related to him incurring or aggravating a left knee injury or disease during service. 5. The Veteran may be unable to secure or follow a substantially gainful occupation, but it is not due to service-connected disabilities because he does not have any. CONCLUSIONS OF LAW 1. The criteria for service connection for a right forearm disability have not been met. 38 U.S.C. §§ 1110, 1111, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 2. The criteria for service connection for a right ankle disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 3. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 4. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 5. The criteria for a TDIU have not been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.16 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty for just under a month during January and February 1995. This matter is on appeal from a May 2010 rating decision (notice was not sent to the Veteran until July 2010). In July 2012, the Veteran testified at a hearing before the undersigned Veterans Law Judge of the Board of Veterans’ Appeals (Board). This matter was remanded by the Board for additional development in June 2014 and again in June 2017. Preliminary Matters VA has a duty to notify a claimant seeking VA benefits. 38 U.S.C. § 5103; 38 C.F.R. § 3.159. Notice must be provided prior to initial adjudication of the evidence necessary to substantiate the benefit(s) sought, that VA will seek to obtain, and that the claimant should submit. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Notice of how ratings and effective dates are assigned also must be provided. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA also has a duty to assist a claimant seeking VA benefits. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). This includes, as suggested by the duty to notify, aiding the claimant in the procurement of relevant records whether they are in government custody or the custody of a private entity. 38 U.S.C. § 5103A(b-c); 38 C.F.R. § 3.159(c)(1-3). A VA medical examination also must be provided and/or a VA medical opinion procured when necessary for adjudication. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Full notification was provided to the Veteran in July and September 2009 letters, prior to initial adjudication via the May 2010 rating decision. Service treatment records and Social Security Administration (SSA) records, which include private treatment records, regarding the Veteran are available. No VA treatment records are available because none have been identified. In March 2010, the Veteran underwent a VA medical examination with an opinion for his right forearm. He underwent VA medical examinations with opinions for his right forearm, right ankle, and right and left knees in December 2014 and September 2017. The opinions from March 2010 and December 2014 will not be discussed, however, as they were deemed inadequate in the Board’s remands. Neither the Veteran nor his representative has raised any other duty to notify or assist deficiencies. Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (procedural arguments that are not raised need not be addressed); Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016) (applying Scott to the duty to assist); Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (concerning the duty to notify). There has been at least the required substantial compliance with the Board’s remands. Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002); Stegall v. West, 11 Vet. App. 268 (1998). Finally, service connection was explained and sources of relevant evidence were discussed at the Veteran’s hearing. 38 C.F.R. § 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). He was given a period of time to submit such evidence thereafter, and the Board’s subsequent remands also sought such evidence. Service Connection Service connection means that the facts, shown by the evidence, establish that an injury or disease resulting in disability was incurred in service, or if preexisting service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Direct service connection requires a current disability, the incurrence or aggravation of an injury or disease during service, and a nexus between them. Holton v. Shinseki, 557 F.3d 1363 (Fed. Cir. 2009). Direct service connection also may be established for any disease diagnosed after separation from service if it was incurred during service. 38 C.F.R. § 3.303(d). Secondary service connection means that a nonservice-connected disability is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310. This includes any increase, or worsening beyond natural progression, in disability resulting from the service-connected disability. Id.; Davis v. Principi, 276 F.3d 1341 (Fed. Cir. 2002). Secondary service connection requires a current disability and a relationship, whether being caused by or having been aggravated by, to a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Only the most relevant evidence must be discussed. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Indeed, the discussion below is limited to this evidence as well as that required to address contentions raised by the Veteran, his representative, or the record. Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545 (2008). When there is an approximate balance of positive and negative evidence on service origin, the degree of disability, or any other point, the claimant must be afforded the benefit of the doubt. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The applicable standard accordingly is at least as likely as not. 1. Right Forearm Disability The Veteran contends his preexisting right forearm injury was aggravated during service. Specifically, he notes that he was accepted for service even though the military knew he had retained hardware from a right forearm surgery. He indicates physical activity during boot camp resulted in pain in his right forearm. He further indicates that he fell extremely hard from a height of 10-12 feet onto the right side of his body during boot camp. His right arm buckled, and he has been disabled with pain and weakness ever since. To be current, there must be a disability near or at the time a claim is filed or at any time during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013); McClain v. Nicholson, 21 Vet. App. 319 (2007). SSA records confirm that the Veteran had open reduction and internal fixation (ORIF) surgery for a right radius fracture in August 1991. It follows that he was status post this procedure thereafter, to include when he filed his claim in June 2009. No diagnosis was made at the March 2010, December 2014, or September 2017 VA medical examinations. However, they reflect that the Veteran has pain, decreased strength, and decreased range of motion in his right arm. This prevents him from jobs requiring lifting, pushing, or repetitive tasks using that arm. He quit driving a forklift, for example, because he could not keep up with the workload operating the controls with that arm. Even absent a diagnosis, the Veteran thus has right forearm symptoms resulting in functional impairment of earning capacity. This constitutes a disability. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Service treatment records show that the Veteran reported being in good health at the time of his enlistment examination in mid-January 1995. Although assessment of his upper extremities was normal, a scar with keloid formation was found on his right forearm. The Veteran reported later in January 1995, when questioned about his dental health, that he had surgery for a broken arm in 1991. In February 1995, he complained of increased right forearm pain with pushups and pulling things which had become constant in February 1995. He denied recent trauma, which would include a fall, but recounted having had surgery for a forearm fracture in the past. X-rays confirmed this by showing an old radial fracture with intact plates and screws, callus formation, and a mild deformity but near anatomical alignment. The Veteran was diagnosed with pain secondary to an old radial fracture. He was medically separated from service because the retained hardware was causing pain with the physical demands of boot camp. In sum, the Veteran undisputedly manifested right forearm problems during service which were attributed to a right forearm injury and treatment prior to service. The presumption of soundness must be considered in this situation. Gilbert v. Shinseki, 26 Vet. App. 48 (2012). A veteran is presumed to be in sound condition upon entrance into service except as to defects “noted.” 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Noted means only defects found on examination. 38 C.F.R. § 3.304(b). despite a right forearm scar being noted at the Veteran’s enlistment examination, no right forearm defect was noted. He therefore is presumed to have been in sound condition with respect to it. To rebut this presumption, there must be clear and unmistakable (obvious and manifest) evidence that the injury or disease both existed prior to service and was not aggravated by service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b); Wagner, 370 F.3d at 1089; Horn v. Shinseki, 25 Vet. App. 231 (2012). There is clear and unmistakable evidence that the Veteran was treated for a right forearm injury prior to his service. Indeed, everything is in agreement on this point. The Veteran reported twice during service that he had surgery for fracturing this forearm prior to service. In making one of those reports, he specified that this occurred in 1991. SSA records confirm that it was August 1991. This equates to about 3.5 years prior to the Veteran’s service. Additional indicators of his preexisting surgical treatment for a right forearm fracture exist as well. His right forearm scar noted at enlistment, a product of the surgery, was not described in any terms conveying recency. The February 1995 X-rays additionally similarly noted that his radial fracture with surgical correction was old. Finally, the September 2017 VA medical opinion included the determination that the Veteran had a preexisting right forearm injury based on the aforementioned history. To find no aggravation by service, the evidence must establish either that there was no increase in disability during service or that any increase in disability was due to natural progression. Wagner, 370 F.3d at 1089. This evidence, as it must be clear and unmistakable, must be affirmative. Insufficient evidence of aggravation is not enough, in other words. Horn, 25 Vet. App. at 231. Here, there is clear and unmistakable evidence that the Veteran’s preexisting right forearm injury did not increase during his service. SSA records did not go into any detail about the severity of this injury after he recovered from the surgery to correct it. As service treatment records from his enlistment did not even not this injury, they clearly did not address its severity either. The baseline accordingly is unknown. A normal baseline will be presumed, as doing so is not prejudicial (and, indeed, most favorable) to the Veteran. Service treatment records document only that the Veteran complained of right forearm symptoms. In addition, subjective decreased sensation over his scar and slightly decreased (4/5) strength was found. His elbow range of motion was full, and his wrist range of motion was full in one direction and to 100 degrees in another. X-rays did not show a change for the worse in his underlying injury. Indeed, there was no new right forearm fracture. There also were no other new abnormalities. The Veteran was advised to seek appropriate orthopedic care after his separation. Whether he did so is unknown. In any event, there next relevant information is dated 7 years after his separation. SSA records reveal that the Veteran complained of right forearm pain and weakness in May 2002. Yet, he had full range of motion and normal strength (5/5), to include for grip, in his right arm. He did not have any sensory deficit. As such, the decreases found during service were not permanent or lasting. Based on the temporary nature of the Veteran’s right forearm problems during service, what he experienced then is best characterized as a flare-up and not an increase in the injury itself. The September 2017 VA medical opinion finally included the determination that the Veteran’s preexisting right forearm injury was not aggravated by his service. The rationale was that service treatment records, particularly X-rays, did not show further damage to his old fracture during his short time in service and that he did not have significant problems after service. In this latter regard, it was noted that his physical fitness after service was prime because he played semi-professional football. SSA records dated from 2002 to 2010 indeed are rife with references to the Veteran playing the sport, even though he stated at the March 2010 VA medical examination that he only coached because he was unable to play. That the Veteran is right handed, and therefore right arm dominant, is significant. He used this arm to play football for years after service, even though he had a preexisting forearm injury. This strongly suggests that the injury was not very significant, as would be expected if it had been aggravated by service, then. Similarly, the rationale for the opinion noted that the Veteran’s right forearm was normal despite his reports of symptoms 7 years after service. The opinion is probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Consequently, it is given more weight than the Veteran’s unsupported contentions to the contrary. The weight of the evidence is against his preexisting injury having been aggravated by service, in other words. The presumption of soundness, in conclusion, has been rebutted. Service connection is denied. 2. Right Ankle Disability The Veteran contends his preexisting right ankle injury was aggravated during service. Specifically, he notes that he was accepted for service even though the military knew he had retained hardware from a right ankle surgery. He indicates that he fell extremely hard from a height of 10-12 feet onto the right side of his body during boot camp. He has been disabled with pain and popping in his ankle as well as instability and loss of feeling in his right leg ever since. To be current, there must be a disability near or at the time a claim is filed or at any time during its pendency. Romanowsky, 26 Vet. App. at 289; McClain, 21 Vet. App. at 319. SSA records confirm that the Veteran had ORIF surgery on his right ankle in 1987. It follows that he was status post this procedure thereafter, to include when he filed his claim in June 2009. No diagnosis was made at the December 2014 or September 2017 VA medical examinations. However, they reflect that the Veteran has pain, numbness, popping, decreased strength, decreased range of motion, and suspected instability in his right ankle. This prevents him from jobs requiring lots of moving, such as walking up and down stairs. Even absent a diagnosis, the Veteran thus has right ankle symptoms resulting in functional impairment of earning capacity. This constitutes a disability. Saunders, 886 F.3d at 1356. Service treatment records reflect that the Veteran reported being in good health at the time of his enlistment examination in mid-January 1995. He also reported having had or having now broken bones, which was clarified as a fractured right fibula at the age of 17 (he was born in July 1970, so he turned 17 in 1987) with no sequelae. Assessment of his lower extremities was abnormal. Yet, the reason specified was mild genu varum, which does not concern the ankles. The Veteran reported later in January 1995, when questioned about his dental health, that he had surgery for a broken leg in 1987. Thereafter, he did not complain of or receive treatment for any right leg problems in general. He also did not complain of or receive treatment for any right fibula or ankle problems in specific. Finally, there is no mention of him falling on his right side or of any other traumatic event involving the right side of his body. As there is no indication that the Veteran has any medical background, he is a lay person. Lay persons are competent to recount personal experiences. Layno v. Brown, 6 Vet. App. 465 (1994). He accordingly is competent to report falling extremely hard from a height of 10-12 feet onto the right side of his body during boot camp. A variety of factors are for consideration in assessing the credibility of competent lay reports. These factors include interest, bias, inconsistency, implausibility, bad character, malingering, desire for monetary gain, and witness demeanor. Pond v. West, 12 Vet. App. 341 (1999); Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24 (1991). No suspicions of dishonesty were raised by the Veteran’s hearing testimony. The fall as reported by him further certainly is plausible. However, he is not credible in making this report based on the other factors. A favorable determination could potentially result in the Veteran’s monetary gain in the form of compensation benefits. His desire for such gain is patent. Indeed, he currently is unemployed and living off SSA benefits. His quest for additional benefits from VA is ongoing in this matter as well as in another matter. The Veteran’s desire for monetary gain makes him interested. Even more significant, his report of a fall during service are inconsistent with the service treatment records. It is reiterated that he denied recent trauma, which includes a fall, in February 1995 in relation to right forearm complaints. This is relevant, as the fall purportedly involved his entire right side. Additionally, it is difficult to conceive of service treatment records being silent with respect to a fall as bad as the Veteran reports. That they are silent strongly suggests that the fall did not occur. AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013); Buczynski v. Shinseki, 24 Vet. App. 221 (2011); Kahana v. Shinseki, 24 Vet. App. 428 (2011). Coupled with the inconsistency with service treatment records, the Veteran’s report is inconsistent with a SSA record. In particular, he indicated in a May 2002 SSA record that he injured his right arm during service but that he injured his body by years of playing football. His body in this context includes his right ankle. Finally, there are numerous instances, or at least strong suggestions, of bad character and malingering which cannot be ignored. The Veteran did not mention that he played football when discussing his life, to include employment history, after service at the September 2017 VA medical examination. He also indicated at the March 2010 VA medical examination that he coached but did not play football. Yet it is reiterated that SSA records are rife with references to him playing football. He further noted wearing a sling on his right arm nearly all the time at this examination. The examiner doubted this, however, because it was ill-fitting and bore someone else’s name and because his musculature was well-maintained. A May 2002 SSA record states that the severity of the Veteran’s alleged “limitation from impairments [is] considered partially credible.” In a February 2003 SSA record, it was noted that his legs are like dead weight. This was based on his report that he must lift them into place and drags them while walking. Yet the references to him playing football in SSA records continue until many years later in 2010. That football is a physically demanding sport is common knowledge. It follows that playing would require legs to be functioning far above the level of dead weight. Similarly, a July 2003 SSA record includes the Veteran’s report that he injured his left knee playing football two days prior. His gait was slow and antalgic. His physician noted being pretty sure he had seen the Veteran walking normally on the street the previous day, however. He, in sum, has a pattern of embellishing problems and omitting or being dishonest about important background information. With service treatment records being silent as to a right ankle, fibula, or even leg problem as well as to a fall impacting the Veteran’s right side, and with his reports of such a fall not being credible, the weight of the evidence is against him having manifested a right ankle problem during service. He did not manifest such a problem, whether via aggravation of a preexisting injury or incurrence of an injury, in other words. Absent manifestation during service, the presumption of soundness need not be considered. Gilbert, 26 Vet. App. at 48. This is true notwithstanding that an August 1991 SSA record confirms the Veteran’s report upon enlistment into service that he broke his right ankle or fibula in 1987 and that the September 2017 VA medical opinion included the determination that the Veteran had a preexisting right ankle injury which was not aggravated by his service. Service connection, in conclusion, is denied. 3. Right Knee Disability The Veteran contends he injured his right knee during service. Specifically, he indicates that he fell extremely hard from a height of 10-12 feet onto the right side of his body during boot camp. He has been disabled with pain in his right knee as well as instability and loss of feeling in his right leg ever since. To be current, there must be a disability near or at the time a claim is filed or at any time during its pendency. Romanowsky, 26 Vet. App. at 289; McClain, 21 Vet. App. at 319. SSA records confirm that the Veteran had surgery/surgeries on his right knee by 2002 or 2003. Thereafter, he was status post surgery, to include in June 2009 when he filed his claim. A July 2011 SSA record documents a diagnosis of osteoarthritis in his right knee. As such, the Veteran has a disability even though no diagnosis was made at the December 2014 or September 2017 VA medical examinations. Arthritis is a chronic disease. 38 U.S.C. § § 1101(3); 38 C.F.R. § 3.309(a). This designation, as it was general, encompasses all types of arthritis. As such, the Veteran’s osteoarthritis is a chronic disease. When a veteran served for 90 days or more during a period of war or after December 31, 1946, and manifested a chronic disease to a compensable degree within a specified number of years after service, there is a rebuttable presumption of service connection. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The Veteran’s service was for far less than 90 days. As such, the presumption need not be considered. Direct service connection still is for consideration, however. Service treatment records reflect that the Veteran reported being in good health at the time of his enlistment examination in mid-January 1995. He denied trick or locked knee at that time. Yet, assessment of his lower extremities was abnormal. Specifically, he was found to have mild genu varum. Genu varum is a deformity in which the knees are abnormally separated and the lower extremities are bowed inward. Dorland’s Illustrated Medical Dictionary 771 (32nd ed. 2012). Service treatment records continue by reflecting that the Veteran thereafter did not complain of, or receive treatment for, any right leg problems in general. He also did not complain of, or receive treatment for, any right knee problems in particular. Finally, there is no mention of him falling on his right side or of any other traumatic event involving the right side of his body. His reports of such a fall are not credible, as set forth above for the right ankle. The weight of the evidence accordingly is against him having manifested a right knee problem during service. He did not manifest such a problem, whether via aggravation of a preexisting injury or incurrence of an injury, in other words. Absent manifestation during service, the presumption of soundness need not be considered. Gilbert, 26 Vet. App. at 48. Nevertheless, the September 2017 VA medical opinion is notable. It included the decision that the Veteran did not have a preexisting right knee disease. The rationale was that there is no confirmation of genu varum following the Veteran’s enlistment examination despite several orthopedic assessments. The September 2017 VA medical opinion also included the determination that the Veteran’s current right knee disability is more likely than not due to injuries from playing football after service. It was noted that he first was seen for a right knee problem in 2002, 7 years after his service, at which time reference was made to him playing football. This is shown in an April 2002 SSA record. The opinion is probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 295. Consequently, it is given substantial weight. September and October 2003 SSA records additionally show that the Veteran’s right knee disability is attributable to playing football after service. For multiple reasons, in conclusion, service connection is denied. 4. Left Knee Disability The Veteran does not contend he injured his left knee during service. Rather, he contends that he developed left knee problems as a result of favoring his right knee, which he injured by falling extremely hard from a height of 10-12 feet onto the right side of his body during boot camp. To be current, there must be a disability near or at the time a claim is filed or at any time during its pendency. Romanowsky, 26 Vet. App. at 289; McClain, 21 Vet. App. at 319. SSArecords confirm that the Veteran had surgery/surgeries on his left knee by 2003. It follows that he was status post surgery thereafter, to include when he filed his claim in June 2009. A July 2011 SSA record additionally documents a diagnosis of osteoarthritis in his right knee. As such, the Veteran has a disability even though no diagnosis was made at the December 2014 or September 2017 VA medical examinations. However, he is not service-connected for a right knee disability in light of this decision. Secondary service connection thus is denied. Although this conclusion is not based on the September 2017 VA medical opinion, it nevertheless is notable in this regard. It indeed conveys that secondary service connection would not be warranted even if the Veteran’s right knee was service-connected. The opinion cited medical literature for the proposition that an injury to one lower extremity does not have a significant impact on the opposite uninjured lower extremity unless the injury resulted in major muscle or nerve damage causing partial or complete paralysis or shortening of the extremity causing a length discrepancy of more than 4-5 centimeters with a resultant altered gait pattern (a significant lurching or limp) over an extended period (years). None of this has been found with respect to the Veteran. The opinion is probative as it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 295. Although not contended by the Veteran, presumptive service connection is denied. It is not considered even though his osteoarthritis is a chronic disease because his service was for far less than 90 days, as set forth above for the right knee. Although not contended by the Veteran, direct service connection also is denied. Service treatment records reflect that he reported being in good health at the time of his enlistment examination in mid-January 1995. He denied trick or locked knee at that time. Yet, assessment of his lower extremities was abnormal. Specifically, he was found to have mild genu varum. Genu varum is a deformity in which the knees are abnormally separated and the lower extremities are bowed inward. Dorland’s at 771. Service treatment records continue by reflecting that the Veteran thereafter did not complain of or receive treatment for any left leg problems in general. He also did not complain of or receive treatment for any left knee problems in specific. Finally, there is no mention of a traumatic event involving his left knee. The weight of the evidence accordingly is against the Veteran having manifested a left knee problem during service. He did not manifest such a problem, whether via aggravation of a preexisting injury or incurrence of an injury, in other words. Absent manifestation during service, the presumption of soundness need not be considered. Gilbert, 26 Vet. App. at 48. This is notwithstanding the September 2017 VA medical opinion which included the determination that the Veteran did not have a preexisting left knee disease. The rationale was the same as that for the right knee. The opinion also included the determination that his current left knee disability is more likely than not due to injuries from playing football after service. It was noted that he first was seen for a left knee problem in 2003, 8 years after service, at which time reference was made to an injury to this knee playing football. This is shown in a July 2003 SSA record. The opinion is probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 295. Consequently, it is given substantial weight. September and October 2003 SSA records also show that the Veteran’s left knee disability is attributable to playing football after service. TDIU A TDIU is granted if a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities rated less than 100 percent. 38 C.F.R. § 4.16(a). The claimant once again must be afforded the benefit of the doubt when there is an approximate balance of positive and negative evidence on this point. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. The applicable standard accordingly is at least as likely as not. The Veteran contends he is unable to work because of his “arm, lower leg, [and] knee,” noting that the SSA deemed him totally disabled. An April 2004 SSA decision indeed found him entitled to disability benefits because of right knee and right arm impairments as well as asthma. However, he is not service-connected for a right knee disability, a right forearm disability, a right ankle disability, or a left knee disability in light of this decision. The Veteran also is not service-connected for asthma or for any other disability. A TDIU therefore is denied. Doing so at this time is not premature notwithstanding that an appeal has been initiated (by filing a notice of disagreement ) concerning service connection for a back disability. The Veteran seeks the “maximum allowable rating” for this disability, which encompasses a contention of unemployability due to it. This contention will be addressed, if warranted (if service connection is granted) as part of the appeal, which is separate from this appeal concerning different disabilities. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Becker, Counsel