Citation Nr: 1807352 Decision Date: 02/05/18 Archive Date: 02/14/18 DOCKET NO. 10-20 820 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for a service-connected left knee disability. 2. Entitlement to service connection for a neck disorder, to include as secondary to the service-connected left knee disability. 3. Entitlement to service connection for a back disorder, to include as secondary to the service-connected left knee disability. 4. Entitlement to service connection for a right shoulder disorder, to include as secondary to the service-connected left knee disability. 5. Entitlement to service connection for a left hip disorder or left lower extremity neurological disorder, to include as secondary to the service-connected left knee disability. 6. Entitlement to service connection for an umbilical hernia, to include as secondary to the service-connected left knee disability. 7. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ORDER A disability rating in excess of 10 percent for the left knee disability is denied. Service connection for a neck disorder is denied. Service connection for a back disorder is denied. Service connection for a right shoulder disorder is denied. Service connection for a left hip disorder or left lower extremity neurological disorder is denied. Service connection for an umbilical hernia is denied. TDIU is denied. FINDINGS OF FACT 1. During the entire appeal period, the Veteran's service-connected left knee disability has been manifested by pain with no lateral instability or recurrent subluxation, no meniscal pathology, normal extension, and flexion that has exceeded 30 degrees. 2. Arthritis of the cervical spine did not become manifest to a degree of 10 percent or more within one year of service separation; a neck disorder is not related to injury or disease in service and is not related by causation or permanent worsening to a service-connected disability or disabilities. 3. Arthritis of the thoracolumbar spine did not become manifest to a degree of 10 percent or more within one year of service separation; a back disorder is not related to injury or disease in service and is not related by causation or permanent worsening to a service-connected disability or disabilities. 4. Arthritis of the right shoulder did not become manifest to a degree of 10 percent or more within one year of service separation; a right shoulder disorder is not related to injury or disease in service and is not related by causation or permanent worsening to a service-connected disability or disabilities. 5. Arthritis of the left hip did not become manifest to a degree of 10 percent or more within one year of service separation; a left hip disorder or left lower extremity neurological disorder is not related to injury or disease in service and is not related by causation or permanent worsening to a service-connected disability or disabilities. 6. An umbilical hernia is not listed among the diseases for which the presumption of service connection for certain chronic diseases, and the provisions regarding chronicity in service and continuity of symptomatology after service must be considered; an umbilical hernia is not related to injury or disease in service and is not related by causation or permanent worsening to a service-connected disability or disabilities. 7. The Veteran's combined disability rating is 10 percent prior to November 28, 2011, and 20 percent since November 28, 2011. 8. The Veteran's service-connected disabilities have not rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for the service-connected left knee disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010 (2017). 2. A neck disorder was not incurred in service; arthritis of the cervical spine is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 3. A back disorder was not incurred in service; arthritis of the thoracolumbar spine is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 4. A right shoulder disorder was not incurred in service; arthritis of the right shoulder is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 5. A left hip disorder or left lower extremity neurological disorder was not incurred in service; arthritis of the left hip is not presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 6. An umbilical hernia was not incurred in service. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 4.9 (2017). 7. The criteria for TDIU have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from February 1971 to May 1972. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions of the RO in Houston, Texas dated in June 2004, May 2007, March 2008, and December 2015. In October 2014, the Veteran presented testimony at a Board hearing, chaired by the undersigned Veterans Law Judge sitting at the RO. The Veteran was informed of the basis for the RO's denial of his claims and he was informed of the information and evidence necessary to substantiate each claim. The record was held open for 60 days to allow the Veteran to supplement the record. A transcript of the hearing is associated with the claims file. 38 C.F.R. § 3.103 (2017). In February 2015, the Board remanded this appeal for additional evidentiary development. The appeal has since been returned to the Board for further appellate action. The RO substantially complied with the remand instructions by obtaining records from the Social Security Administration, by obtaining outstanding VA treatment records, and by obtaining a new VA examination for the left knee. In February 2015, the Board also dismissed a claim of entitlement to service connection for a left shin injury, an issue on appeal at that time. The Board's decision with respect to that claim is final. See 38 C.F.R. § 20.1100 (2017). The Board acknowledges the receipt of a Notice of Disagreement regarding the TDIU issue in November 2016. The issue of TDIU entitlement is a component of the rating claim on appeal in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009) (where there is evidence of unemployability raised by the record during a rating appeal period, the TDIU is an element of an initial rating or increased rating). Rating Claim Disability ratings 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. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2014). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2017). A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert at 54. In a July 1972 rating decision, the RO granted service connection for a left knee disability and assigned an initial rating of 10 percent under Diagnostic Code 5099-5010, effective May 17, 1972. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2017). The current appeal arises from an increased rating claim that was received at the RO on February 18, 2004. Under Diagnostic Code 5010, arthritis due to trauma is rated as degenerative or osteoarthritis. Under Diagnostic Code 5003, degenerative arthritis is rated on the basis of limitation of motion. Limitation of motion of motion of the knee joint is rated under Diagnostic Codes 5260 and 5261. Under Diagnostic Code 5260, limited flexion of the knee merits a rating of 30 percent where flexion is limited to 15 degrees; 20 percent where flexion is limited to 30 degrees; 10 percent where flexion is limited to 45 degrees; and 0 percent where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limited extension of the knee merits a rating of 50 percent where extension is limited to 45 degrees; 40 percent where extension is limited to 30 degrees; 30 percent where extension is limited to 20 degrees; 20 percent where extension is limited to 15 degrees; 10 percent where extension is limited to 10 degrees; and 0 percent where flexion is limited to5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The report of a June 2004 VA Joints Examination reveals that the Veteran was taking no medication on a regular basis for his knee disability and he was not utilizing crutches, braces, canes, or other assistive devices. The Veteran related a history of difficulty with his knee dating back to service. He described pain over the anterior and anterio-medial aspects of the knee. He described grinding and popping that increased with climbing or kneeling. He stated that his symptoms were worse with squatting, climbing, kneeling, or bending. He stated that his last medical evaluation was in 1972, and he denied any interval injuries. On examination, he walked with a non-antalgic gait. He had full range of motion of the left knee. He had no effusion. He had no meniscal signs. There was no evidence of instability. He reported tenderness to palpation around the patellofemoral articulation, more medial than lateral. X--ray evaluation was unremarkable. The examiner diagnosed chondromalacia. The report of a December 2004 VA Joints Examination reveals complaint of pain and associated stiffness and swelling. He denied a history of instability, lack of endurance, or locking. No swelling or deformity was found on examination. The Veteran had a normal, non-antalgic gait. He was able to do transfers without any pain. Bilateral flexion was from 0 to 140 degrees, extension was 0 degrees, Stable medial and lateral collateral ligaments were noted. Negative anterior posterior drawer testing was noted. Negative McMurray's test was noted. There was adequate alignment. The examiner diagnosed left knee chondromalacia patella with moderate symptomatology. A November 2006 VA examination includes the notation that the Veteran was walking with a steady gait unassisted and in no acute distress. The report of a January 2008 VA Joints Examination reveals complaint of the left knee giving way. The Veteran reported numbness in both legs, which started in his buttocks and continued through his knee to his calf. When he would get the numbness, and he could not walk at all. He reported weakness in the muscles. On examination, there was no effusion. There was some mild patellar crepitus with range of motion, which was non-painful. The knee was stable to varus/valgus stress testing both in extension and in 30 degrees of flexion. He had a negative Lachman test, negative anterior-posterior drawer tests, and negative McMurray test. Range of motion of the knee was form 0 to 135 degrees, active, and passive, against resistance. There was no pain, fatigue, or incoordination with repetitive motion. X-rays revealed no acute bony abnormalities. There was normal joint space on the left side. The examiner found that the neurological symptoms of the left lower extremity were radicular in nature, as opposed to knee-related, and ordered an X-ray of the lumbar spine, which confirmed markedly narrowed disc spaces and spondylolysis. A June 23, 2008, Emergency Department Note reveals left knee and toe effusions with similar episodes noted in the past. There was no recent trauma (VBMS record 05/07/2010). A July 4, 2008, VA Primary Care Note reveals a recent diagnosis of gout (VBMS record 05/07/2010 at 37). The report of a July 2015 VA Joints Examination reveals complaint that, during flares, the Veteran was unable to walk without a walker. Range of motion was measured from 0 to 125 degrees. This range of motion was found not to contribute to functional loss. There was pain at rest, with examination, and with non-movement. There was no evidence of pain associated with weightbearing, and no evidence of crepitus. After 3 repetitions range of motion was measured from 0 to 115 degrees. The Veteran reported 1-2 flares every 3-4 months, which he described as "severe," lasting until he could get an injection. Pain, weakness, fatigability or incoordination significantly limited functional ability with flares, but did not significantly limit functional ability with repeated use over a period of time. During flares, range of motion was estimated to be 0 to 110 degrees. Strength was 5/5 with no muscle atrophy. There was no history of recurrent subluxation or lateral instability. Testing of anterior, posterior, medial, and lateral, instability was normal. There was no history of recurrent effusion. The Veteran also was found not to have, and had never had, meniscus (semilunar cartilage) conditions. The left knee disability did not impact his ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.). X-rays revealed mild tricompartmental osteoarthritic changes. The report of an October 2016 VA Joints Examination reveals range of motion was normal, from 0 to 140 degrees. There was evidence of pain with weight bearing, but no crepitus. There was no additional loss of motion or functional loss after 3 repetitions. Pain, weakness, fatigability, or incoordination do not significantly limit functional ability with repeated use over time, or with flares. Muscle strength with flexion and extension was 5/5. There was no muscle atrophy. There was no history of recurrent subluxation or lateral instability. Testing of anterior, posterior, medial, and lateral, stability was normal. A history of recurrent effusion was reported. The Veteran did not have, and had never 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 also did not have, and had never had, meniscus (semilunar cartilage) conditions. The left knee disability did not impact his ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.). After a review of all of the evidence, the Board finds that a disability rating in excess of 10 percent is not warranted for the service-connected left knee disability. At no time has flexion been limited to the extent of 30 degrees, which is required for the next-higher 20 percent rating under Diagnostic Code 5260. Indeed, even the criteria for a 10 percent rating are not met under that code. At no time has extension been limited to the extent of 10 degrees required for a 10 percent rating under Diagnostic Code 5261. The current 10 percent rating is substantiated only by the reports of painful motion, which is noncompensable under either diagnostic code, but which warrants a rating of 10 percent under Diagnostic Code 5003, given the X-ray evidence of arthritis. The Board has considered other diagnostic codes for the knee. However, testing has consistently shown no subluxation, no lateral instability, and no meniscal pathology. A compensable rating under Diagnostic Code 5257 requires either recurrent subluxation or lateral instability. A compensable rating under Diagnostic Codes 5258 and 5259 requires meniscal pathology. Moreover, the condition diagnosed in this case is arthritis and chondromalacia. The specific conditions noted under Diagnostic Codes 5262 and 5263 are not shown. The Board notes that the Veteran has multiple diagnoses affecting the left lower extremity, including gout and lumbar radiculopathy. The Veteran attributes all of his symptoms to the service-connected disability. However, the medical evidence does not. A May 2009 Orthopedic Note suggests the Veteran's neurological symptoms are actually a manifestation of lumbar radiculopathy. The Board finds that the Veteran is competent to describe his symptoms, but he is not competent to attribute them to a specific pathology, where, as here, there are multiple disorders affecting the left lower extremity (see the Board's discussion of general principles regarding lay evidence, infra). The medical evidence in this case clearly shows that his left knee is only minimally symptomatic, and that the majority of his complaints are associated with nonservice-connected disorders. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (the Board is precluded from differentiating between symptomatology attributed to a non service-connected disability and a service-connected disability in the absence of medical evidence which does so), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The Veteran has been provided adequate examinations in this case, and findings compliant with Correia v. McDonald, 28 Vet. App. 158 (2016) have been provided. There is no additional development necessary to render a decision on this claim. In sum, the Board finds that the Veteran's service-connected left knee disability has been manifested by painful motion which is noncompensable in degree. Accordingly, the Board concludes that the criteria for a higher rating or separate rating for the service-connected left knee is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Service Connection Claims VA law provides that, for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, or other than a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation, except if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. 38 U.S.C.A. §§ 1110, 1131 (West 2014). Entitlement to service connection on a direct basis requires (1) evidence of current nonservice-connected disability; (2) evidence of in-service incurrence or aggravation of disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current nonservice-connected disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310(a),(b); Wallin v. West, 11 Vet. App. 509, 512 (1998). For specific enumerated diseases designated as "chronic" there is a presumption that such chronic disease was incurred in or aggravated by service even though there is no evidence of such chronic disease during the period of service. In order for the presumption to attach, the disease must have become manifest to a degree of 10 percent or more within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Presumptive service connection for the specified chronic diseases may alternatively be established by way of continuity of symptomatology under 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a) Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service treatment records reveal no complaints, treatment, or diagnoses pertinent to the Veteran's neck, right shoulder, or left leg (other than the knee). There are also no complaints, treatment, or diagnoses pertinent to an umbilical hernia. The Veteran does not contend that he was treated in service or had symptoms in service regarding these claims. Service treatment records in July 26-7, 1971, reveal complaint of back pain in the lumbar region. There was a large spasm in the lower back. An August 27, 1971, note reveals complaint of pain in low back due to a fall on a ladder on August 26, 1971. There was some redness and muscle tightness, but no contusion. After service, the first record of treatment for any of these complaints comes decades later. A December 17, 2004, X-ray of the spine revealed mild degenerative changes of the thoracic spine (VBMS record 11/23/2004). On examination in December 2004, it was noted that the Veteran was found to have an umbilical hernia in January 2004 (VBMS record 01/26/2005). An increased rating examination for the left knee in December 2004 included information pertinent to the service connection claims. The Veteran stated that he had onset of joint and back pain beginning "two years ago." The veteran stated that all of his problems started with complaints of heart problems and shortness of breath. The Veteran reported an injury to his back in 1979 when he fell. He also reported another fall in 1982, resulting in a fracture of the T12-L1. Bilateral shoulders and cervical spine showed adequate range of motion. The Veteran was assessed as overweight, and his range of motion was reduced by his body habitus, but the examiner considered this as normal range of motion for him. Sensory examination was within normal limits. Motor examination was 5/5 (VBMS record 01/26/2005). In a letter received in February 2005, the Veteran reported falling in January 2004 due to his knee collapsing. He claimed that, at this time, he incurred an umbilical hernia and a bruised sternum. He reported he was unable to stand for very long, and walking was very difficult. A March 11, 2005, VA Primary Care Note reveals complaint of chronic low back pain with symptoms consistent with sciatica. The Veteran reported that he had a fall 3 days prior because of weakness in his knee (VBMS record 04/22/2005). A July 24, 2006, Fall Risk Assessment includes the question whether the Veteran has a history of falling, to which the Veteran responded: "No." (VBMS record 10/04/2006). The report of a November 2006 VA Examination reveals the Veteran's complaint of a stomach hernia and left leg nerve damage, which he claimed was due to his left knee disability. He claimed that a fall from a truck in 2004 caused his umbilical hernia. On examination, there was a 3-centimeter bulge noted at the umbilicus. The examiner stated that, it is obvious from the examinations from the Neurology Department, as late as October 2006, and previous compensation and pension examinations, that he sustained a fall and a workman's compensation injury in 1979, which resulted in a spinal injury, and he is trying to relate all of the spinal injury problems to the left knee chondromalacia patella. However, there is no indication that the fall that he sustained in 1979 had any relationship with the chondromalacia patella. The examiner noted that the Veteran had been examined for the knee, and there was no new evidence that the Veteran had to present to him as to why he thinks the chondromalacia patella was the cause of all of the other problems. He had provided no evidence that would change any opinion that had previously been made. He just seemed to indicate that he thinks that all of the injuries after he got out of the service should be related to the military service. He gave no reason other than he feels that the knee is the reason why he has all of the problems that he has now. According to the examiner, there is no medical reasoning behind what the Veteran was indicating. The last X-ray that was taken in 2004 showed a totally normal left knee. There was no way the examiner could connect the left knee chondromalacia patella to the current symptomatology of the left hip pain and left nerve damage in the leg. In discussing the history with him, he became discouraged about the examination. The Veteran indicated that he did not want any further examination and/or X-rays done and left the examining area. The examiner's opinion was that the left hip condition, unspecified, and upper left leg with nerve damage condition, was not due to the service-connected chondromalacia patella left knee. A January 9, 2007, Neurology Note reveals complaint of pain in the right upper extremity following a coronary bypass operation in 2006. Differential diagnoses included brachial plexus injury versus C8/T1 radiculopathy. The examiner thought it was most likely a brachial plexus injury, consistent with pain and timing after open-heart surgery (VBMS record 02/01/2008). An April 10, 2007, Neurology Note reveals that an MRI had been ordered to rule out radiculopathy. A February 2007 MRI revealed multilevel degenerative changes in the lumbar spine with no lumbar spinal canal stenosis or foraminal narrowing. There was also a small midline protrusion of the C5-6 disc without cord compression (VBMS record 02/01/2008). The report of a March 2007 VA Examination reveals the Veteran's complaint of a fall in 2004, when he fell off a truck injuring his ribcage causing a hernia. The Veteran contended that the left knee disability was the cause of his fall. The examiner opined that it is less likely than not that the Veteran's umbilical hernia was caused from an injury to his ribcage when he fell off the truck. He also opined that there is no evidence of service relation for the umbilical hernia. The rationale was that, in most cases, an umbilical hernia is a weakness in the ring of muscle that surrounds the naval. It is usually present at birth, but it is not noticeable at that time. Before birth the umbilical ring usually closes off. When it does not, tissue can bulge through the opening of the naval. As this is usually a developmental abnormality found at birth, it is less likely than not caused by the Veteran's fall off a truck, and less likely than not caused by or related to his chondromalacia of the left patella. A February 21, 2008, X-ray of the right shoulder revealed no significant abnormality (VBMS record 05/07/2010). The report of a February 2008 VA Examination reveals the Veteran's report that he fell off a truck in 2004 because his left knee gave way. This caused injury to his back and right shoulder. He reported right shoulder pain with radiation to his ring finger and small finger. If he sleeps on his right side, he will get numbness and tingling in his hands. There was no neck pain. It was all muscular shoulder pain. There had been no change in his lower back condition since evaluation in January 2008, with the exception of range of motion testing. He had an MRI of his cervical spine on February 13, 2007. It showed small midline protrusion at C5-6 disc without compression. There was no right-sided lesion identified to account for his right sided symptoms. He had an antalgic gait and appeared to be in moderate distress secondary to his lower back pain. He had some muscle spasms in the right trapezius. Motor function was 5/5 in all muscle groups in the upper extremities. Sensation was intact. The examiner opined that the cervical spine and lower back were not related to the left knee chondromalacia. The rationale was that there is nothing in the file to indicate instability in his left knee. He has never had any evidence of internal derangement to the knee, other than some mild patellofemoral syndrome, which would not account for his leg giving way, causing him to fall, injuring his neck and back. A May 12, 2009, VA Orthopedic Clinic Note reveals the Veteran's complaint that his leg gives way and he has no control over the left leg afterwards. Testing revealed the knee was stable to valgus/varus stress and stable to anterior/posterior drawer. There was no clinical evidence of laxity. It was thought that the claimed weakness may be originating from the spine (VBMS record 05/07/2010 at 71). A December 2014 affidavit from a friend states that she has seen the Veteran fall and that this is obviously due to defective left knee. A December 2014 letter from a friend states that she has seen him fall many times. A December 2014 letter from a friend stats that he had witnessed the Veteran's left knee fail on him. After a review of all of the evidence, the Board finds that the claimed disorders of the neck and low back, the left shoulder, the left leg, and the umbilical hernia, are not related to service and are not proximately due to, a result of, or aggravated by a service-connected disability. The Veteran has been diagnosed with cervical and thoracolumbar spine pathology, to include a thoracic compression fracture and degenerative disease of the cervical and thoracolumbar spine. He has also been diagnosed with brachial plexus injury stemming from heart surgery. Associated with these diagnoses, he has been found to have upper and lower extremity radiculopathy. This would appear to be the principal diagnosis for the left hip and right shoulder, as findings for degenerative disease have largely been negative or assessed as not "significant" (see January 1, 2015, shoulder X-ray). The Veteran he has been found to have calcific tendonitis of the right shoulder, as well as gout affecting multiple joints. Other diagnoses include an umbilical hernia. To the extent of any arthritis, such as in the thoracolumbar spine and cervical spine, this did not become manifest to a degree of 10 percent or more within one year of service separation. Notably, under VA law, manifestation of degenerative arthritis or traumatic arthritis requires X-ray evidence. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. Umbilical hernias and tendonitis are not included among the presumptive diseases. Accordingly, the presumption of service connection for arthritis does not apply to any of the claims. There is no medical opinion that purports to relate any of the claimed disorders either to service or to a service-connected disability. The only evidence that favors the claim on the question of nexus comes from the Veteran. The Veteran essentially asserts that his service-connected knee caused a fall from the bed of a truck in 2004, and that the other disorders were caused by this fall. Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 ('sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer'); 38 C.F.R. § 3.159(a)(2). There are two questions on which the Veteran's statements may be relevant. The first is whether any of the claimed disorders is etiologically related to the 2004 fall, either by causation or aggravation. The second is whether the fall was actually caused by his left knee disability. Setting aside for a moment the inconsistencies in the Veteran's various descriptions of the results of the fall, the Board finds that the Veteran is generally competent to describe his perception of events surrounding the fall. However, as a layperson without medical training, the Veteran is not competent to attribute the cause of the fall to his service-connected knee disability. It is important to reiterate that the Veteran has multiple disorders that could potentially affect the function of his knee joint. With the exception of arthritis and chondromalacia, these conditions are not service-connected. While the Board is precluded from differentiating between symptomatology attributed to a non service-connected disability and a service-connected disability in the absence of medical evidence which does so, Mittleider, supra), in this case, the medical evidence provides such a differentiation. Notably, the November 2006 and February 2008 examiner's addressed this assertion and found that his knee was not so impaired due to the service-connected disability as would lead to the reasonable expectation that it would give way. Notably, strength of the knee was normal and full, in both flexion and extension, his muscles were not atrophied, and there has never been any lateral instability. The Board finds these opinions to be consistent with the record, which demonstrates that functional impairment of the left knee has been manifested only by pain and occasional swelling, but not by weakness or instability. Accordingly, the Board finds that Veteran's assertion that his service-connected left knee disability caused him to fall is neither competent nor accurate. Returning to the Veteran's inconsistent account, it is notable that the Veteran's account at the December 2004 VA knee examination did not describe a fall in 2004. Rather, the Veteran stated that he had onset of joint and back pain beginning "two years ago." He further stated that all of his problems started with complaints of heart problems and shortness of breath. The Veteran first described the 2004 fall in a letter received in February 2005, at which time, he stated it occurred in January 2004, well prior to the December 2004 examination. However, he only attributed the umbilical hernia and a bruised sternum to the fall. He has subsequently attributed all of the claimed disorders to the fall. This inconsistency undermines the credibility the Board attaches to his descriptions. There is evidence attributing the left lower extremity neurological impairment to lumbar radiculopathy. There is also evidence of gout in the lower extremities. However, these are not service-connected conditions. Thus, the extent that either of these disorders may have caused a fall in 2004, service connection cannot be established because the cause of the fall was not the service-connected left knee disability. Regarding the assertion that his umbilical hernia was caused by the fall, the Board finds that this is not competent evidence. The Veteran is competent to describe the onset of symptoms, but he is not competent to state that a particular incident, such as a fall, caused or aggravated the disorder, which was found by the March 2007 examiner to be a congenital condition, thus present from birth. Even if aggravation were substantiated in the fall, the Board's finding that the fall was not caused by the left knee disability would still preclude a grant of service connection for this condition. Regarding the lay evidence submitted in favor of the claim, to the extent this evidence substantiates the Veteran's claim that he has sustained falls, this is not in dispute. To the extent these accounts relate the cause of the falls to the Veteran's left knee disability, they are also not competent evidence. To reiterate, the Veteran's attribution of a fall, or multiple falls, to his service-connected left knee disability is neither competent evidence, nor credible evidence. The Veteran's attribution of the onset of claimed thoracolumbar spine and cervical spine arthritis, right shoulder tendonitis, left lower extremity neurological impairment, or an umbilical hernia, to any specific fall, is not competent evidence as the onset and cause of these particular disorder are not lay-observable events. In sum, the Board finds that the claimed disorders of the neck, back, right shoulder, left lower extremity, and the umbilical hernia, are not related to service and are not proximately due to, a result of, or aggravated by, a service-connected disability. As such, the Board concludes that service connection for these claimed disorders is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. TDIU Claim It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a)(1), 4.15. A claim for a total disability rating based upon individual unemployability presupposes that the rating for the service-connected disability is less than 100 percent, and only asks for TDIU because of subjective factors that the objective rating does not consider. Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In evaluating a veteran's employability, consideration may be given to his level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or impairment caused by non service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The term substantially gainful occupation is not specifically defined for purposes of the regulations governing TDIU. However, marginal employment is not considered substantially gainful employment. Marginal employment includes situations in which an individual's annual income does not exceed the poverty threshold for one person. Employment may be marginal even when the individual's earned income exceeds the poverty threshold if such individual is employed in a protected environment such as a family business or sheltered workshop. 38 C.F.R. § 4.16(a). A total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, 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 ratable at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a). In this case, service connection is in effect for a left knee disability rated at 10 percent since May 17, 1972, tinnitus, rated at 10 percent since November 28, 2011, and hearing loss, rated at 0 percent since November 28, 2011. The combined rating is 10 percent since May 17, 1972, and 20 percent since November 28, 2011. Thus, the schedular criteria for TDIU are not met. Pursuant to 38 C.F.R. § 4.16(b), when a claimant is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for eligibility for a total rating set forth in 38 C.F.R. § 4.16(a), such case shall be submitted for extraschedular consideration. For a veteran to prevail on a claim for a total compensation rating based on individual unemployability on an extraschedular basis, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In Hatlestad v. Derwinski, 1 Vet. App. 164 (1991), the United States Court of Appeals for Veterans Claims (Veterans Court) referred to apparent conflicts in the regulations pertaining to individual unemployability benefits. Specifically, the Court indicated there was a need to discuss whether the standard delineated in the controlling regulations was an "objective" one based on the average industrial impairment or a "subjective" one based upon the veteran's actual industrial impairment. In a pertinent precedent decision, the VA General Counsel opined that the controlling VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as the result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a subjective standard. It was also determined that "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91. After a review of all of the evidence, the Board finds that the Veteran's left knee disability, hearing loss, and tinnitus have not rendered him unable to secure or follow a substantially gainful occupation. The Veteran has not asserted that his hearing loss and tinnitus contribute substantially to unemployability. While he has asserted that his left knee disability contributes to unemployability, he has done so in the context of all of his musculoskeletal, respiratory, neurological, psychiatric, and systemic disorders. While the Veteran has been found to be disabled by the Social Security Administration, it was not based solely on his left knee or hearing impairment, but on transient ischemic attack, congestive heart failure, compression fracture of the thoracic spine, severed ulnar nerve, left finger amputation, right thumb injury, hypertension, depression, and osteoarthritis of the hips and knees. The Board has found that the left knee is accurately rated at 10 percent disabling, that it is not manifested by weakness or instability, and that it has not contributed to falling. These findings are pertinent to a determination as to his expected occupational impairment resulting from this condition. Accordingly, the Board concludes that referral of this issue for extraschedular consideration is not appropriate, and that a TDIU is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD L. Cramp, Counsel Copy mailed to: Texas Veterans Commission Department of Veterans Affairs