Citation Nr: 18159265 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 18-02 563 DATE: December 18, 2018 ORDER The application to reopen a claim for pain in the left shoulder is granted. Entitlement to service connection for a left shoulder disability is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a left wrist disability, to include carpal tunnel syndrome (CTS) and arthritis is denied. Entitlement to service connection for a right wrist disability, to include carpal tunnel syndrome (CTS) and arthritis is denied. Entitlement to service connection for a left ankle disability is denied. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and bipolar disorder is denied. Entitlement to an increased rating greater than 30 percent for hiatal hernia with reflux and history of duodenitis is denied. REMANDED Entitlement to an increased rating greater than 30 percent for residuals of compression fracture of L1 with kyphosis and wedging of T12, L1 is remanded. Entitlement to an increased rating greater than 30 percent for residuals of fracture of the supracondyle, left femur, is remanded. Entitlement to an increased rating greater than 10 percent for avulsion neuropathy, left peroneal nerve with reduced dorsiflexion of the foot is remanded. FINDINGS OF FACT 1. An unappealed January 1980 rating decision denied entitlement to service connection for pain in the left shoulder. 2. Evidence received since the January 1980 rating decision is new, material, and probative as to a previously unestablished fact necessary to substantiate the left shoulder claim. 3. The Veteran does not have a left shoulder disability that first manifested in service, within one year of service, and is not otherwise caused by service. 4. The Veteran does not have a right shoulder disability that first manifested in service, within one year of service, and is not otherwise caused by service. 5. The Veteran does not have a left wrist disability that first manifested in service, within one year of service, and is not otherwise caused by service. 6. The Veteran does not have a right wrist disability that first manifested in service, within one year of service, and is not otherwise caused by service. 7. The Veteran does not have a left ankle disability that first manifested in service, within one year of service, and is not otherwise caused by service. 8. The Veteran does not have an acquired psychiatric disorder that first manifested in service, within one year of service, and is not otherwise caused by service. 9. The Veteran’s hiatal hernia with reflux and history of duodenitis is not manifested by hematemesis or melena or other symptom combination productive of severe impairment of health. CONCLUSIONS OF LAW 1. The January 1980 rating decision that denied entitlement to service connection for pain in the left shoulder is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2018). 2. Evidence received since the January 1980 rating decision in relation to the Veteran’s claim for entitlement to service connection for pain in the left shoulder is new and material, and, therefore, the claim is reopened. 38 U.S.C. §§ 5108, 7104 (2012); 38 C.F.R. § 3.156 (2018). 3. The criteria for entitlement to service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 4. The criteria for entitlement to service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 5. The criteria for entitlement to service connection for a left wrist disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 6. The criteria for entitlement to service connection for a right wrist disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 7. The criteria for entitlement to service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 8. The criteria for entitlement to service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 9. The criteria for hiatal hernia with reflux and history of duodenitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.84a, Diagnostic Code (DC) 7346 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Navy from November 1958 to November 1962, from February 1963 to July 1975, and from August 1975 to June 1979. As an initial matter, the Board notes that on August 16, 2018, the Federal Circuit issued an order in the appeal of Procopio v. Wilkie, No. 17-1821 (U.S. Fed. Cir.). The order stated that the questions before the Federal Circuit include the following: “Does the phrase ‘served in the Republic of Vietnam’ in 38 U.S.C. § 1116 unambiguously include service in offshore waters within the legally recognized territorial limits of the Republic of Vietnam, regardless of whether such service included presence on or within the landmass of the Republic of Vietnam?” As of the date of this decision, Procopio is pending. As this appeal contains at least one issue that may be affected by the resolution of Procopio, the Board will “stay” or postpone action on the issues of entitlement to service connection for a bilateral eye disability, prostate cancer, esophageal cancer, hypertension, diabetes mellitus, and right lower extremity neuropathy. Given that the remaining issues are not impacted by the above stay, they are adjudicated herein. As to the right shoulder disability claim, the Board notes that the RO considered the claim as a petition to reopen based on the provision of new and material evidence, which the RO reopened; however, the record does not indicate that a final denial with respect to the right shoulder is of record. As such, the Board will proceed with the issue as an original claim for entitlement to service connection. As to the acquired psychiatric disorder claim, the Board observes that the RO adjudicated the claims of PTSD and bipolar disorder separately; however, given the Court’s holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009) that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled the Board has combined the issues into one overarching claim for an acquired psychiatric disorder. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131 (2012). Certain diseases, to include arthritis and other organic diseases of the nervous system, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2018). To establish a right to compensation for a present disability, an appellant must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the alternative, service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). 1. Whether new and material evidence has been submitted sufficient to reopen a claim for entitlement to service connection for pain in the left shoulder The Veteran has one year from notification of a RO decision to initiate an appeal by filing a notice of disagreement (NOD) with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105 (b) and (c) (2012); 38 C.F.R. §§ 3.160 (d), 20.201, and 20.302(a) (2018). The Veteran was denied entitlement to service connection for pain in the left shoulder in a January 1980 rating decision. The Veteran did not appeal the rating decision by submitting a timely NOD or other indication of disagreement with the rating decision or submit new and material evidence within one year. The denial of his claim consequently became final. See 38 C.F.R. §§ 3.156, 20.302, 20.1103 (2018). As a result, the claim of entitlement to service connection may now be considered if new and material evidence has been received since the time of the last final adjudication. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); Evans v. Brown, 9 Vet. App. 273 (1996). Under 38 C.F.R. § 3.156 (a), evidence is considered “new” if it was not of record at the time of the last final disallowance of the claim. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Finally, new and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. In determining whether evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992). Additionally, when determining whether the Veteran has submitted new and material evidence to reopen a claim, consideration must be given to all the evidence since the last final denial of the claim. Evans v. Brown, 9 Vet. App. 273 (1996). Moreover, the Veteran need not present evidence as to each element that was a specified basis for the last disallowance, but merely new and material evidence as to at least one of the bases of the prior disallowance. See Shade v. Shinseki, 24 Vet. App. 110 (2010) (holding that it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element). Since the time of the last final denial, a January 2015 VA examination report included a current diagnosis of a left shoulder strain. The January 1980 rating decision denied the Veteran’s claim, in relevant part, based on the absence of a current diagnosis of a left shoulder disability. Pursuant to the Court’s holding in Shade and presuming the credibility of the evidence for the sole purpose of determining whether the claim should be reopened, the Board concludes that the above evidence demonstrates that the Veteran has a current left shoulder disability. The evidence is new and material. Having reopened the left shoulder claim, the Board will evaluate below the claim on the merits. 2. Entitlement to service connection for a left shoulder disability 3. Entitlement to service connection for a right shoulder disability The Veteran contends that he has left and right shoulder disabilities due to an in-service August 1972 ship engine room explosion and/or was caused or aggravated by his service-connected back disability. Service treatment records from the August 1972 accident including a detailed report of immediate treatment do not include right or left shoulder symptoms or diagnoses. In May 1978, the Veteran reported intermittent left shoulder pain that was suspected to be musculoskeletal. In January 1979, the Veteran reported that he had an injury to the right shoulder in 1972 with episodes of numbness of the little and ring fingers on the right. Recently he threw clay pigeons and developed weakness in the right wrist. Testing showed no evidence of neuropathy. There was no weakness and the examiner did not conclude that there was neuropathy. In February 1979, the Veteran had bilateral shoulder weakness with numbness of the ulnar nerve. A March 1979 medical board report included complaints of right shoulder weakness. On examination, the right shoulder was normal. X-rays of the right shoulder also were normal. A July 1981 special orthopedic examination noted that the Veteran could have a right shoulder disability based on complaints of recurrent episodes of ulnar distribution weakness of the right hand. X-rays of the right shoulder were normal. During a July 1981 VA examination, the Veteran stated that in 1975 he hit his left elbow very hard on a car door, with resulting left thumb, index, and middle finger numbness. X-rays reportedly were negative. The Veteran contended that the pain in the left elbow and hand was attributed to a diagnosed hiatal hernia. Within 3 years, the Veteran indicated that the pain had spread to the left shoulder and he had constant left shoulder problems from that point. During the same examination, the Veteran stated that during a severe in-service accident he suffered a paralyzed right upper extremity. The orthopedic consultant found a small fracture in his small bone of the right shoulder. The paralysis lasted 1.5 months. On examination, the Veteran had normal range of motion in the shoulders. The examiner indicated that the Veteran could have some sort of injury to the right shoulder or right upper extremity based on the Veteran’s description of recurrent episodes of ulnar distribution weakness of his right hand, but there was no neurological or anatomic abnormality on examination or x-ray. The assessment was transient numbness and paralysis of the right upper extremity, without residuals, cause undetermined, and pain and numbness, left upper extremity, cause undetermined. A January 1997 private treatment record indicated that in November 1996 the Veteran had a workplace incident after which he experienced an aching discomfort in the right shoulder and was unable to lift his arm. The assessment was a complete rotator cuff tear of the right shoulder and the Veteran underwent surgery. In March 1997, the Veteran was diagnosed with right acromioclavicular joint dislocation / separation and he underwent another surgery. Records document ongoing problems with the right shoulder following surgery. A January 2012 private treatment record documented a motor vehicle accident earlier that month. Although he did not hit his shoulders at the time of the accident, when exiting the vehicle, the Veteran hit his left shoulder resulting in a significant bruise. The Veteran reported his right shoulder post-service injuries at work, but otherwise did not describe any in-service problems with either shoulder. A May 2013 private treatment record documented left shoulder pain for about 6 months that began without a specific history of injury. X-rays showed no bony abnormalities. The assessment was pain and impingement, left shoulder. The Veteran was afforded a VA shoulder examination in January 2015. The examiner diagnosed left shoulder strain. The Veteran contended that he separated his right shoulder and injured his rotator cuff about one year prior to retirement. Despite treatment, there was ongoing pain. As to the left shoulder, he began to experience pain and was diagnosed with impingement. Following examination and discussion of the Veteran’s history, the examiner diagnosed right shoulder residuals status post-surgery and left shoulder strain. A more precise diagnosis could not be provided due to the lack of objective data demonstrating disability. The examiner concluded that it was less likely than not that the right shoulder disability was incurred in or caused by service. The opinion was based on review of the record, current medical literature, and clinical experience. The examiner noted the absence of objective evidence of a right or left shoulder disability in service, with treatment first occurring in 1997. As such, there was insufficient evidence to demonstrate a nexus between the current right shoulder disability and service. As to the left shoulder disability, the examiner concluded that there was no objective evidence to support a finding that the left shoulder strain was due to or the result of the Veteran’s back condition. Current medical literature contained no objective evidence to support a nexus for the left shoulder strain being due to or caused by the service-connected back disability. In a December 2017 statement, the Veteran complained that decreased circulation in his right arm due to shoulder impingement that caused weakness in the hand. The Board concludes that the claimed disabilities had their onset after service and are not otherwise related to service or service-connected disability. As to the Veteran’s general contentions that his disabilities were incurred as a result of his active service, he is competent to report symptoms related to his claimed disabilities; however, there is not clear evidence of a claimed continuity of shoulder symptoms from service and there is evidence of post-service injuries to both shoulders. To the extent he has been experiencing ongoing shoulder problems not evidenced by the record, the Veteran as a layperson is not competent to attribute any intermittent but ongoing symptoms to his in-service injury or his service-connected back disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). By contrast, the Board finds the VA medical opinion of significant probative value. The examiner concluded that the Veteran’s right and left shoulder disabilities were not at least as likely as not caused by service and were not caused or aggravated by the service-connected back disability. The rationale noted the absence of right or left shoulder diagnoses in service, despite multiple examinations of the joints or for many years after service. As to the secondary claim, current medical literature did not support a finding that a shoulder disability was caused or aggravated by a back disability. The medical 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, 304 (2008). Finally, the Board is aware of the provisions of 38 C.F.R. § 3.303(b), relating to chronicity and continuity of symptomatology in establishing service connection and that such provisions apply to those chronic conditions, such as arthritis, specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013). However, arthritis of the shoulders was not noted during service or within one year of separation from service. Indeed, x-rays in service were negative for arthritis or other disability. Moreover, there is not a clear contention of a continuity of shoulder problems from service that could serve as a basis for granting the claim pursuant to the above provisions. To the extent there is a contention of a continuity of problems, there are numerous examinations in the intervening years from service that definitively found no evidence of a shoulder disability and there is medical evidence concluding that the current shoulder disabilities are unrelated to service. As such, the Board finds that the provisions of 38 C.F.R. § 3.303(b) are not for application. In summary, the Veteran is not competent to attribute his claimed disabilities to his active service. There is no medical evidence linking any of the claimed disabilities to service. In light of the evidence, the Board concludes that the preponderance of the credible evidence is against the service connection claims. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule does not apply, and the claims must be denied. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 4. Entitlement to service connection for a left wrist disability, to include CTS and arthritis 5. Entitlement to service connection for a right wrist disability, to include CTS and arthritis The Veteran appears to contend that he has current right and left wrist disabilities due to his August 1972 accident. That said, the Board notes that the Veteran’s most recent statements suggest that he is not claiming bilateral wrist disabilities, but disabilities to the hands and fingers. (To the extent that the Veteran wishes to raise hand and/or finger claims, the Board encourages the Veteran to file such a claim(s) with the RO.) In January 1979, the Veteran reported that he had an injury to the right shoulder in 1972 with episodes of numbness of the little and ring fingers on the right. Recently he threw clay pigeons and developed weakness in the right wrist. Testing showed no evidence of neuropathy. There was no weakness and the examiner did not believe there was neuropathy. In March 1979, the Veteran reported weakness in the right arm, with numbness in the ulnar nerve distribution, particularly aggravated by heavy use of the right upper extremity. On examination, there was decreased sensation in the ulnar nerve distribution on the right and positive Tinel’s at the olecranon groove. During a December 1979 VA examination, the Veteran reported tingling in the left arm, thumb, and fingers accompanied by pain radiating from the left side at C5-C6 down through the shoulder and elbow. A July 1981 special orthopedic examination noted that the Veteran could have a right upper extremity disability based on complaints of recurrent episodes of ulnar distribution weakness of the right hand. X-rays of the shoulder and elbow were normal, but no x-rays of the wrist were taken. During a July 1981 VA examination, the Veteran stated that in 1975 he hit his left elbow very hard on a car door, with resulting left thumb, index, and middle finger numbness. X-rays reportedly were negative. The Veteran contended that the pain in the left elbow and hand was attributed to a diagnosed hiatal hernia. Three years later, the Veteran began to experience intermittent increased numbness and tingling in the above fingers. During the same examination, the Veteran claimed that in 1977 he was throwing some clay pigeons and injured his right elbow, with loss of strength of the right hand and numbness of the right middle, ring, and little fingers. These symptoms reoccurred twice without any obvious reason and the fingers now had a cold and damp feeling. Following normal nerve conduction studies, the Veteran was told that he might have incurred slight damage to the ulnar nerve that subsequently recovered. On examination, the upper extremities were normal. The assessment was transient numbness and paralysis of the right upper extremity, without residuals, cause undetermined, and pain and numbness, left upper extremity, cause undetermined. The Veteran was afforded a VA examination in January 2015. The Veteran claimed that he did not have CTS or any other condition of the right wrist. Instead, he had some pain due to arthritis in the hand, but not in the wrist. Following examination, the examiner agreed that there was no evidence of right CTS or other neuropathic condition of the right wrist / hand. A more precise diagnosis could not be rendered because there was no objective data to support a more definitive diagnosis. In a July 2017 statement, the Veteran indicated that, “I never claimed carpel tunnel joint of [the] right wrist. The incompetent claims examiner at the March 2015 comp eval submitted this when I mentioned the fact that I have arthritis in the joints of my right hand. I know the difference in the two.” The Board concludes that the claimed disabilities had their onset after service and are not otherwise related to service. As to the Veteran’s general contentions that his disabilities were incurred as a result of his active service, he is competent to report symptoms related to his claimed disabilities; however, there is not clear evidence of a claimed continuity of wrist symptoms from service. To the extent he has been experiencing ongoing wrist problems not evidenced by the record, the Veteran as a layperson is not competent to attribute any intermittent but ongoing symptoms to his in-service injury. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Indeed, the Board finds such contentions regarding the right and left wrists problematic in light of the Veteran’s denial of ongoing wrist problems during his 2015 VA examination and thereafter, instead reporting that he had hand problems but not wrist problems. The medical evidence of record supports such a finding. The Board is aware of the provisions of 38 C.F.R. § 3.303(b), relating to chronicity and continuity of symptomatology in establishing service connection and that such provisions apply to those chronic conditions, such as arthritis, specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013). However, arthritis of the wrists was not noted during service or within one year of separation from service. Indeed, x-rays in service were negative for arthritis or other disability. Moreover, there is not a clear contention of a continuity of wrist problems from service and the Veteran actually has denied such symptoms. As such, the Board finds that the provisions of 38 C.F.R. § 3.303(b) are not for application. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule does not apply, and the claims must be denied. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 6. Entitlement to service connection for a left ankle disability The Veteran contends that he has a left ankle disability due to his August 1972 in-service accident and/or was caused or aggravated by his service-connected left knee disability. Following an August 1972 engine room explosion, the Veteran had a sprained left ankle and x-rays showed that the anterior lip of the articular surface of the tibia could chip off. Following 3 months of limited duty in 1973, there was absent left ankle dorsiflexion, but this was attributed to the service-connected peroneal disability. In February 1979, the Veteran complained of ankle stiffness and pain. There was some tenderness and decreased motion on examination. X-rays were negative and the ultimate diagnosis was left ankle pain in the March 1979 medical board determination, which also noted the Veteran’s complaints of ankle stiffness and pain, particularly with weather changes and prolonged walking. There was recurrent mild swelling, but no giving way at the ankle. On examination, the left ankle was normal other than minimal swelling and tenderness over the anterior joint line. During a December 1979 VA examination, the Veteran reported recurring pain in the left ankle that increased with extended use of the left leg. The examiner noted an in-service fracture of the lower end of the left femur, with fracture of the left ankle. There was paralysis of the peroneal nerve and following 3 operations the Veteran had partial return of function of the peroneal nerve. On examination, there was some weakness in the dorsiflexion of the left foot and hypesthesia from the knee to the ankle on the lateral aspect of the leg. Despite the foregoing, no specific diagnosis as to the left ankle was provided. Examination of the left ankle revealed slight widening of the medial side of the joint space and this may be secondary to the changes in the left lower femur and knee. The examiner could not make out any findings to indicate previous fracture. In May 2012, the Veteran was noted to have arthritis in the left ankle. In December 2012, the Veteran reported a history of left lower extremity injury with constant numbness in the at the lateral aspect of the left leg. On examination, there was reduced range of motion of the left ankle. No specific diagnosis was made as to the left ankle, but there was a noted history of left peroneal nerve injury after a left lower extremity injury in 1972. In support of his claim, the Veteran submitted a July 2012 private treatment record that included an examination of the left ankle showing swelling and limited dorsiflexion and plantar flexion. There also was tenderness along the anterior joint line. X-rays showed severe arthritis of the left ankle with wear of the lateral aspect of the joint. The impression was left ankle degenerative joint disease with valgus angulation genu varus deformity with degenerative joint disease. In a March 2015 statement, the Veteran alleged that he had suffered a broken left ankle in service during an engine room explosion when he injured multiple other joints for which he is service connected. The Veteran acknowledged that the injury was “not addressed at the time.” Over the years, arthritis in the ankle had developed to the point that it was debilitating. At times, his ankle would freeze up. In April 2017, the Veteran underwent a VA ankle examination. The examiner concluded that the Veteran did not have a currently diagnosable left ankle disability. The Veteran reiterated his prior assertion that he had a current left ankle disability due to a 1972 accident for which he was service-connected for the residuals. He was not treated for the left ankle in service or after service. He had been seeing a private primary care provider for over 10 years for other issues not involving the ankle. Around 2010 or 2011 he was referred to a foot doctor, where x-rays were taken and the Veteran believed he was told that he had “arthritis,” although he was not sure if the arthritis was of the foot or ankle. The Veteran declined x-rays at the time of examination and reported that the entire left side of his body had experienced problems since the in-service accident. The Veteran noted that he had left foot drop after the accident, but had worked hard to regain his strength. He denied pain or flare-ups of the ankle. On examination, the right ankle was normal, but the left ankle had limited dorsiflexion from -10 to 10 degrees and plantar flexion from -10 to 55 degrees. The examiner indicated that the limited motion was consistent with residuals of bony deformity of the lower end of the tibia and fibula and the Veteran’s self-reported post-service left tibia / fibula fracture. That said, total range of motion of the left ankle was within normal limits. There was no objective evidence of “arthritis” and the Veteran declined an x-ray. Left ankle muscle strength was normal, without atrophy. There was no evidence of instability. A September 2017 addendum opinion is of record, based on the Veteran’s provision of the July 2012 private record showing left ankle arthritis. The examiner concluded that it was less likely than not that the left ankle arthritis was incurred in or caused by service. The rationale noted the in-service documentation of left ankle pain and sprain, but that there was nothing suggestive of left ankle joint involvement. All the Veteran’s complex in-service symptoms were consistent with his service-connected left peroneal nerve injury, which caused the decreased active dorsiflexion at the time of his initial claim and for which service connection was granted. The in-service left ankle problems were transient in nature and the left ankle was within normal limits during examination in service. There was no evidence of chronicity in active duty or in the years following separation from service, which was supported by the statements provided by the Veteran at the time of his April 2017 VA examination. Many years after service, at age 72 in 2012, the Veteran was diagnosed with left ankle arthritis. As to whether the left ankle disability was caused or aggravated beyond its natural progression by the service-connected residuals, fracture of the supracondyle, left femur, with knee instability, the examiner indicated that there was no evidence of causation or aggravation due to the service-connected disability. The rationale noted that there was no evidence of aggravation, based on the medical evidence, medical literature, and clinical experience. As to causation, the April 2017 VA examination report showed no significant muscle or nerve injury and the Veteran did not have a significant gait abnormality. The Board concludes that the left ankle disability had its onset after service and is not otherwise related to service or service-connected disability. As to the Veteran’s general contentions that his disabilities were incurred as a result of his active service, he is competent to report symptoms related to his claimed disabilities. That said, the Veteran as a layperson is not competent to attribute his symptoms to a specific left ankle disability due to the complexity of distinguishing symptoms due to ankle dysfunction as opposed to his left peroneal nerve disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). By contrast, the Board finds the VA medical opinion of significant probative value. The examiner concluded that the Veteran’s left ankle disability was not at least as likely as not related to service and was not caused or aggravated by the service-connected peroneal nerve disability. The rationale noted that during service all of his problems were linked to the peroneal nerve disability (for which he is separately service connected). As to relating the current left ankle disability to the left knee disability by causation or aggravation, there was no medical literature to support a finding of aggravation and causation was not established due to the absence of significant gait abnormality or significant muscle or nerve injury. The medical 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, 304 (2008). Finally, the Board is aware of the provisions of 38 C.F.R. § 3.303(b), relating to chronicity and continuity of symptomatology in establishing service connection and that such provisions apply to those chronic conditions, such as arthritis, specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013). However, arthritis of the left ankle was not noted during service or within one year of separation from service. Indeed, x-rays in service were negative for arthritis or other disability. To the extent there is a contention of a continuity of problems, there are numerous examinations in the intervening years from service that attributed left ankle problems exclusively to the separately service-connected peroneal nerve disability and did not find a discrete left ankle disability. As such, the Board finds that the provisions of 38 C.F.R. § 3.303(b) are not for application. In summary, the Veteran is not competent to attribute his left ankle disability to his active service. There is no medical evidence linking the disability to service. In light of the evidence, the Board concludes that the preponderance of the credible evidence is against the claim. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 7. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and bipolar disorder The question for the Board is whether the Veteran has a current acquired psychiatric disorder other than PTSD that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Veteran was afforded a VA examination in January 2015. At that time, the Veteran denied having filed a claim for PTSD or seeking entitlement to service connection for PTSD and wondered who had filed the claim without his permission. The medical evidence of record does not otherwise demonstrate a diagnosis or ongoing treatment for mental health problems. The Board concludes that the Veteran does not have a current acquired psychiatric disorder and has not had one at any time during the pendency of the claims or recent to the filing of the claims. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). To the extent that the Veteran believes he has current diagnoses of PTSD and/or bipolar disorder, he is not competent to provide a diagnosis in this case. The issues are medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. INCREASED RATING 8. Entitlement to an increased rating greater than 30 percent for hiatal hernia with reflux and history of duodenitis Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). Separate DCs identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2018). The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2018). VA must consider whether the Veteran is entitled to “staged” ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2018). The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). While diseases of the digestive system, particularly within the abdomen, differ in the site of pathology, they produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title “Diseases of the Digestive System,” do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. See also 38 C.F.R. § 4.113 (2018). Disabilities of the digestive system are rated in accordance with 38 C.F.R. § 4.114, DCs 7200-7348. Section 4.114 provides that ratings under DCs 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the DC that reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. The Veteran’s service-connected gastrointestinal disability is currently rated as 30 percent disabling under DC 7346 for hiatal hernia. The Veteran claims the rating does not accurately depict the severity of his current condition. Based on the Veteran’s predominant symptoms and disability, GERD, DC 7346 is the most appropriate DC, as well as the DC most beneficial to the Veteran. Under DC 7346, a 10 percent rating is warranted for a hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, DC 7346. The Veteran was afforded a VA examination in January 2015. The Veteran had a noted diagnosis of Barrett’s esophagus from 2012. The Veteran took daily medication and tried not to go to bed with food in his stomach. These efforts had reduced his discomfort. Symptoms included pyrosis, reflux, and sleep disturbances that occurred 4 or more times per year and lasted for less than 1 day. There was no esophageal stricture, scars, or other pertinent physical findings. The esophageal conditions did not affect the Veteran’s ability to work. The Veteran underwent another VA examination in October 2017. The Veteran reported that he avoided lying down after eating, but medication was keeping his heartburn and reflux symptoms well controlled. He denied hematemesis, ulcers, or significant food intolerances. Signs and symptoms included infrequent episodes of epigastric distress, pyrosis, and reflux. There was no esophageal stricture or spasm. There were no associated scars and the symptoms did not affect occupational functioning. After review of the evidence, the Board finds that a rating greater than 30 percent is not warranted for the Veteran’s hiatal hernia for any period on appeal. The Veteran has consistently reported infrequent episodes of epigastric pain, pyrosis, reflux, and sleep disturbances. In order to warrant a 60 percent disability rating, the Veteran would need to display symptoms of pain, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combination productive of severe impairment of health. The Veteran has not demonstrated hematemesis or melena and he has not described and the record does not demonstrate that the hiatal hernia results in severe impairment of health. As such, the Board cannot conclude that the evidence demonstrates persistently recurrent symptoms productive of severe impairment of health as necessary for a rating greater than 30 percent. In this case, the Board finds no provision upon which to assign a rating greater than 30 percent for the Veteran’s gastrointestinal problems. Furthermore, the Board concludes that the Veteran’s symptomatology has been sufficiently consistent throughout the appellate time period that assignment of staged ratings is not for application. REASONS FOR REMAND 1. Entitlement to an increased rating greater than 30 percent for residuals of compression fracture of L1 with kyphosis and wedging of T12, L1 is remanded. 2. Entitlement to an increased rating greater than 30 percent for residuals of fracture of the supracondyle, left femur, is remanded. 3. Avulsion neuropathy, left peroneal nerve with reduced dorsiflexion of foot is remanded. As to the back disability claim, the United States Court of Appeals for Veterans Claims (Court) held in Correia v. McDonald, 28 Vet. App. 158 (2016) that to be adequate a VA examination of the joints must, wherever possible, include the results of range of motion testing on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint in compliance with 38 C.F.R. § 4.59. The most recent VA examination report in October 2017 failed to include all the information directed by Correia and 38 C.F.R. § 4.59. The examination report noted that there was no evidence of pain with weight bearing, but otherwise failed to include any discussion of passive range of motion or non-weight bearing testing. As the Veteran is not in receipt of the maximum rating available for limitation of motion of the back, the Board finds that the VA examination reports of record do not comply with Correia and that a new examination is warranted. As to the left peroneal nerve claim, the Board notes that prior VA examinations of the back, including in January 2015, also have considered his left peroneal nerve injury. Moreover, at times during the appellate process the Veteran has argued that he has sciatic radiculopathy of the left lower extremity. In that regard, the Board notes that a February 2018 imaging report submitted by the Veteran indicates possible nerve root impingement at multiple levels of the left lumbosacral spine. Given the potentially intertwined nature of the back claim with left lower extremity problems and that a remand for a new back examination could result in new evidence regarding the left peroneal nerve claim, the Board concludes that a remand of the peroneal nerve issue also is necessary prior to final adjudication of the claim. As to the left knee / femur claim, the Veteran most recently was afforded a VA examination in October 2017. The examiner diagnosed degenerative arthritis of the left knee. The Veteran reported being able to walk short distances, but that he tired easily. He did daily stretching exercises, despite decreased ranges of motion and stiffness that had worsened over the years. The Veteran currently was taking no medication for the knee. He used a raised shoe to level his shortened left leg for walking. The Veteran denied any current problems with the right knee and denied any associated flare-ups. On examination, the right knee was normal. The left knee included range of motion from 0 to 100 degrees. The Veteran was unable to do squatting, carrying, or heavy lifting activities due to left leg weakness. There was no objective evidence of pain on examination, including on weight bearing. There was no tenderness to palpation or crepitus. Repetitive use did not adversely affect range of motion or function. Muscle strength in the left knee was 4 out of 5 in both flexion and extension. There was no ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. On testing, there was no anterior instability, posterior instability, medial instability, or lateral instability. There was no meniscal condition. In a December 2017 statement, the Veteran indicated that he was unable to walk the 15 to 20 yards to the mailbox without a rest and that he had difficulty making dinner for his family. In a September 2018 statement, the Veteran reported that the degenerative arthritis in the left knee had reached the point that it was severe. He also experienced laxity and had fallen twice in the last 3 months because of it. There was deteriorating strength in the quadricep muscle due to stretched ligaments in the joint. There also were problems with left knee subluxation and varus angulation had gone beyond moderate to disabling. The Board takes the Veteran’s September 2018 statement as an assertion that his left knee / femur disability has worsened since the time of the October 2017 VA examination. The Veteran discussed how his problems had gone from “moderate” to “disabling” and outlined multiple specific worsening problems. Based on the foregoing, the Board finds that a remand for a new examination is necessary. The matters are REMANDED for the following action: 1. Schedule the Veteran for VA examinations to determine the current nature and severity of his back, left knee / femur, and left peroneal nerve disabilities. The electronic claims file should be made available to and reviewed by the examiner. Full range of motion testing must be performed where possible. The joint(s) involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint in compliance with 38 C.F.R. § 4.59. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain the basis for this decision. If the Veteran reports flare-up episodes not present during the examination, the examiner must provide an assessment of any additional loss of function based on the Veteran’s reporting. 2. After the above is complete, readjudicate the Veteran’s claims. If a complete grant of benefits is not awarded, issue a supplemental statement of the case (SSOC) to the Veteran and his representative. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel