Citation Nr: 1820652 Decision Date: 04/04/18 Archive Date: 04/16/18 DOCKET NO. 07-40 405 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to higher staged initial ratings for service-connected right knee ligament strain, status post arthroscopy, rated noncompensable prior to June 22, 2009, and 10 percent from June 22, 2009 (except for a period of a temporary total (100 percent) convalescence rating pursuant to 38 C.F.R. § 4.30). 2. Entitlement to service connection for a back disability, to include as secondary to service connected right knee disability. 3. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Veteran represented by: William C. Herren, Attorney at Law ATTORNEY FOR THE BOARD J. R. Higgins, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army June 1982 to June 1985. These matters are before the Board of Veterans' Appeal (Board) on appeal from rating decisions issued in November 2006 (right knee and low back) and April 2016 (TDIU) by the Department of Veteran Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. During the pendency of the appeal, in an April 2011 rating decision, the RO granted a 10 percent staged initial rating, effective June 22, 2009, for the Veteran's service-connected right knee disability. A February 2018 rating decision granted a temporary total (100 percent) evaluation from January 31, 2018 through March 31, 2018 for the service-connected right knee disability, pursuant to 38 C.F.R. § 4.30, based on surgical treatment necessitating convalescence. A 10 percent rating was thereafter continued from April 1, 2018. Because the RO did not assign the maximum disability rating possible throughout the rating period on appeal, the appeal for higher staged initial evaluations remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). These matters were most recently before the Board in February 2017 and have been returned for appellate consideration. This appeal was processed using the Virtual VA/VBMS paperless claim processing system. Accordingly, any future consideration of this Veteran's case should take into account the existence of this electronic record. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. From July 25, 2006 through June 21, 2009, the service-connected right knee disability was manifested by complaints of right knee pain, without demonstration of painful or limited motion, and without demonstration of instability or subluxation, or impairment of the tibia, fibula, or meniscus. 2. From June 22, 2009 to the present, the service-connected right knee disability has been manifested by pain, productive of, at worse, forward flexion limited to 100 degrees and extension limited to 10 degrees, with no ankylosis, no recurrent subluxation or lateral instability, no effusion of the joint, or impairment of the tibia, fibula, or meniscus demonstrated. 3. A low back disability, manifested more than one year after separation, is not shown to be casually or etiological related to an in-service event, injury or disease, and has not been shown by competent evidence to have been caused or aggravated by service-connected disability. CONCLUSIONS OF LAW 1. From July 25, 2006 through June 21, 2009, the criteria for a compensable initial evaluation for service-connected right knee disability have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.59, 4.71a Diagnostic Codes 5256-5262 (2017). 2. From June 22, 2009 to the present, (with exclusion of the period of assignment of a temporary total (100 percent) convalescence rating) the criteria for an initial evaluation in excess of 10 percent for service-connected right knee disability have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.59, 4.71a Diagnostic Codes 5256-5262 (2017). 3. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) Neither the Veteran nor his representative has raised any issues with regard to the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The issues on appeal were most recently remanded by the Board in February 2017. At that time, the RO was instructed as follows: (1) to retrieve outstanding medical records, (2) schedule the Veteran for a VA examination to determine the current severity of his service-connected right knee disability, (3) obtain a medical opinion as to the etiology of the Veteran's low back disability, and (4) issue a Supplemental Statement of the Case (SSOC) if the claims remained denied. A claimant has the right to substantial compliance with remand directives. Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the United States Court of Appeals for Veterans Claims Court (Court) or the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders); see also D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required). Here, the outstanding medical records were obtained and associated with the record. The Veteran was scheduled for a VA examination to determine the severity of his service connected right knee disabilty, and to obtain an etiological opinion as to the Veteran's claimed low back disability. The issues were subsequently readjudicated, and an SSOC was issued in November 2017. As such, the Board finds that there has been substantial compliance with its July 2017 remand directives. The Board will now review the merits of the Veteran's claims. II. Entitlement to higher staged initial ratings for service-connected right knee disability, rated noncompensable prior to June 22, 2009, and 10 percent from June 22, 2009 (excluding a period of a temporary total (convalescence) rating). Disability ratings are assigned under a schedule for rating disabilities and based on a comparison of the veteran's symptoms to the criteria in the rating schedule. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Disability evaluations are determined by assessing the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the ratings schedule. Individual disabilities are assigned separate Diagnostic Codes, and ratings are based on the average impairment of earning capacity. See 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). If there is a question as to which evaluation should be applied to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). The primary focus in a claim for increased rating is the present level of disability. Although the overall history of the veteran's disability shall be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, a staged rating is warranted if the evidence demonstrates distinct periods of time in which a service-connected disability exhibited diverse symptoms meeting the criteria for different ratings throughout the course of the appeal. Fenderson v. West, 12 Vet. App, 119, 125-126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform 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 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 which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2017); see also 38 C.F.R. §§ 4.45, 4.59 (2017). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Particularly, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," resulting in functional impairment that more nearly approximates the criteria for the next highest rating. Id.; see 38 C.F.R. § 4.40. With particular respect to the joints, the disability factors reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45 (2017). The provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 shall be considered in determining the degree of limitation of motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the schedule is to recognize painful, unstable, or misaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. When the evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca, 8 Vet. App. at 206. Particularly, pain must affect some aspect of, "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," resulting in functional impairment that more nearly approximates the criteria for the next highest rating. Id.; see 38 C.F.R. § 4.40. Precedent opinions of the VA's General Counsel have held that dual ratings may be given for a knee disorder, with one rating for instability (Diagnostic Code 5257) and one rating for arthritis with limitation of motion (Diagnostic Codes 5003 and 5010). VAOPGCPREC 9-98 and 23-97. Another such opinion held that separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension) may be assigned for disability of the same joint. VAOPGCPREC 9-2004. Normal range of motion for the knee is 140-0 degrees. See 38 C.F.R. § 4.71, Plate II Under the Diagnostic Code 5261, extension of the leg limited to 45 degrees warrants a 50 percent rating; extension limited to 30 degrees warrants a 40 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 10 degrees warrants a 10 percent rating; and extension limited to 5 degrees warrants a noncompensable rating. 38 C.F.R. § 4.71a, DC 5261. . Flexion of the leg limited to 15 degrees is compensated with a 30 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; flexion limited to 45 degrees warrants a 10 percent rating; and flexion limited to 60 degrees warrants a noncompensable rating. 38 C.F.R. § 4.71a, DC 5260. Under Diagnostic Code 5257, slight recurrent subluxation or lateral instability warrants a 10 percent rating, moderate recurrent subluxation or lateral instability warrants a 20 percent rating, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. 38 C.F.R. § 4.71a, DC 5257. The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2017). With respect to the Veteran's claims adjudicated on the merits herein, the Board first notes that it has reviewed all of the evidence in the Veteran's claims file, placing an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record, but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claims. In this case, the November 2006 rating decision on appeal awarded service connection for right knee ligament strain, status post arthroscopy, and assigned a noncompensable initial rating, effective from July 25, 2006. As noted above, an April 2011 rating decision assigned a 10 percent staged initial rating, effective from June 22, 2009. A February 2018 rating decision granted a temporary total (100 percent) evaluation from January 31, 2018 through March 31, 2018 for the service-connected right knee disability, pursuant to 38 C.F.R. § 4.30, based on surgical treatment necessitating convalescence. A 10 percent rating was thereafter continued from April 1, 2018. The Veteran now contends that his service-connected right knee disability warrants a compensable initial rating prior to June 22, 2009, and a rating in excess of 10 percent from June 22, 2009 (with exclusion of the period of assignment of a temporary total convalescence rating). A. Prior to June 22, 2009 Review of the medical treatment records for this period detail ongoing complaints of right knee pain. However, there is no objective medical evidence of joint swelling, inflammation, or deformity. The Veteran's knee movement was described as full and painless. In October 2006, the Veteran was afforded a VA examination to determine the nature and etiology of his right knee disability. A review of the record was noted, including the Veteran's 1984 right knee arthroscopy. The Veteran reported instability and locking of his right knee, but no episodes of dislocation or recurrent subluxation. The Veteran reported use of a cane, but did not use a cane during the examination. Upon examination, the examiner found that the Veteran's joints were not painful nor was the Veteran limited by pain, fatigue, weakness, or lack of endurance following repetitive movement. There was no objective evidence of painful motion, edema, effusion, instability, weakness, tenderness, redness, heat, abnormal movement, or guarding of movement. The Veteran's gait was normal with no functional limitations on standing or walking. The Veteran's range of motion was noted at 0 to 140 degrees. The medial and lateral collateral ligaments were intact. The anterior and posterior cruciate ligaments were intact. The medial and lateral meniscus tests were negative, bilaterally. There was no crepitus felt on active, passive, or repetitive range of motion. Based on a review of the evidence of the record, the Board finds that the Veteran's service-connected right knee disability was correctly rated as non-compensable disabling for the rating period on appeal prior to June 22, 2009. Clinical evidence of record, and the Veteran's statements provided during VA treatment and examinations show that he underwent a right knee arthroscopy in 1984. The Veteran reported chronic pain, weakness, stiffness, instability, locking, swelling, and lack of endurance. However, the objective medical evidence contradicts the Veteran's reported symptomology. The October 2006 VA examiner noted that there was no objective manifestations of painful motion, edema, effusion, instability, weakness, tenderness, redness, heat, abnormal movement, or guarding of movement. Furthermore, based on the foregoing evidence, the Board finds that a compensable evaluation cannot be assigned under Diagnostic Codes 5256, 5257, 5260, 5261, or 5262. With regard to Diagnostic Code 5256 (knee ankylosis) and 5257 (recurrent subluxation or lateral instability), there is no objective evidence that Veteran suffers from ankylosis or recurrent subluxation or lateral instability. During the VA examinations in October 2006, testing maneuvers were performed and disclosed no such instability. The Veteran reported use of a cane, however, the Board points out that the use of assistive devices, such as a cane, does not, by itself denote knee instability. Moreover, the Board notes that the Veteran did not use a cane during his October 2006 VA examination. With regard to Diagnostic Codes 5260 (limitation of flexion) and 5261 (limitation of extension), the Veteran's right knee showed full range of motion of 0 to 140 degrees with no signs of additional loss due to factors such as pain, instability, fatigue, flare-ups, or weakness. Without demonstration of limitation of flexion, or extension limited to at least 10 degrees, a compensable rating cannot be assigned on the basis of limitation of motion under either diagnostic code. Accordingly, a compensable rating under Diagnostic Code 5260 and/or 5261 is not appropriate at any time during the rating period prior to June 22, 2009. In this regard, the Board notes that, while the Veteran had complaints of right knee pain, the objective clinical evidence demonstrated there was no painful right knee motion. See October 2006 VA examination report. As such, the provisions of 38 C.F.R. § 4.59 does not warrant a minimum compensable rating. Therefore, the Board finds that the preponderance of the evidence of record is against assignment of a compensable initial rating for the rating period prior to June 22, 2009. B. From June 22, 2009 to the present Here, the Veteran is currently assigned a 10 percent disability rating under the 38 C.F.R. § 4.71, Diagnostic Codes 5299-5257 for limited and painful motion of his right knee. The evidence of record reflects complaints and objective observations of chronic right knee pain since June 2009. A VA treatment record dated June 2009 detailed complaints of chronic right knee pain with joint tenderness and increased pain with motion, extension and flexion. A November 2009 VA medical treatment record provided that the examiner was unable to fully evaluate the Veteran's knee due to pain. A May 2010 examination of the right knee revealed healed arthroscopic portals with a range of motion of 0-130 degrees with no posterior or anterior instability at 90 degrees, a negative Lachman's Test, no valgus or varus instability, a normal patella, mild medial joint tenderness, and no effusion or rotary instability. The examiner, however, noted pain with patellofemoral grind. In March 2011, the Veteran underwent a VA examination of his right knee. A review of the record was noted, including the Veteran's 1984 right knee arthroscopy. See VA Examination March 2011. At that time the Veteran reported chronic pain, weakness, stiffness, instability, locking, and lack of endurance, swelling, dislocations, tenderness, and redness of the right knee. The Veteran reported that he was unemployed; however the examiner noted that Veteran reported working as a car detailer in 2010. The Veteran also provided that his right knee affected his daily activities such as walking, bending, standing, and sleeping. Upon examination, the examiner noted no objective pain at rest or with passive range of motion, but the Veteran complained of extreme pain during active range of motion. There was no edema, effusion, or instability. The Veteran complained of global tenderness, however when distracted there was no tenderness to be found. There was no abnormal movement, but the Veteran did have guarding of movement with active range of motion. However, the examiner reported no guarding when the Veteran was distracted. There was no deformity, malalignment, weakness or ankylosis. No evidence of inflammatory arthritis was noted. The examiner observed apparent loss of joint function with the Veteran's active range of motion, but no joint function loss with distracted passive range of motion testing. As to Deluca factors, the examiner found no objective medical evidence of pain, weakness, fatigue, lack of endurance, or in coordination with distracted movements, but Veteran reported pain, weakness, and lack of endurance with active range of motion. The examiner observed non-distracted range of motion measurements of flexion of 0-30 degrees and extension from 30-0 degrees. However, the examiner noted flexion of 0-90 degrees and an extension from 90-0 degrees with distracted range of motion. Furthermore, the examiner reported that orthopedic evaluation found the right knee range of motion to be 0-130 degrees, with no instability, negative Lachman's test, no varus or valgus instability, normal patella tracking, normal motor strength, and no rotary instability. The Veteran's medial, lateral, anterior, and posterior cruciate collateral ligaments were intact. There was no instability of either knee. The Veteran was able to perform range of motion testing, however the Veteran complained of extreme pain on movement of the right knee during testing, but when distracted the Veteran reported no pain. The examiner also noted that the orthopedic notes documented an order to the Veteran to stop the use of the knee brace and continue with physical therapy. The examiner found the Veteran's physical examination inconsistent and stated that, "I must conclude any complaints related to right knee condition are totally unrelated to his post arthroscopy condition especially in view of the fact of his physical examination, his conflicting physical findings, distracted examination, and the Veteran's movements when he was aware that he was observed, the ortho clinic's near normal range of motion, the order not to use the knee brace, the claim that he could not drive and observed driving away ....., and the claim that he had not worked for several years, and the noted work history from the ortho clinic history that he works as a car detailer." The Board notes that the March 2011 VA examiner cited the inability to accurately fully evaluate the Veteran's right knee disability due to unreliability of the Veteran's statements and over reporting of symptoms. As noted above, the March 2011 examiner provided that there was a marked difference in the Veteran's physical findings when the Veteran was aware he was being observed versus being distracted during testing. The Veteran complained of pain when he was aware that the examiner was watching, but when distracted the Veteran was able to complete the testing without any objective signs of pain. The Veteran's active range of motion was a flexion of 0-30 degrees and 30-0 degrees extension, when he was aware of the examiner's observation, but the examiner noted a flexion of 0-90 degrees and an extension of 90-0 degrees, when distracted. With that in mind, the Board limits the probative value of the Veteran's statements made concerning pain and the physical findings during the March 2011 VA examination. The Veteran submitted a Disability Benefits Questionnaire (DBQ) for his right knee in May 2016. The DBQ was completed by the Veteran's private physician, Dr. M. The Veteran reported that his right knee was injured in-service resulting in pain, which has made his daily activities difficult. The Veteran's range of motion measurements were flexion of 0-110 degrees and extension of 90-5 degrees with no change in range of motion after repetitive testing. Dr. M. noted that there was no range of motion movements that were painful on active and passive testing, but indicated that pain did contribute to functional loss or additional range of motion. Additionally, the private physician found objective signs of pain when the knee is used in weight-bearing and non-weight bearing, which resulted in functional loss. The examiner noted that the Veteran had tenderness, or pain on palpation at the medial and lateral patella with limited and painful motion. As to Deluca factors, the examiner found that pain, weakness, fatigability, or incoordination significantly limited the functional ability during flare-ups, or when the joint is used repeatedly. The private physician provided that due to pain and/or functional loss during flare-ups, or when the joint was used repeatedly, the Veteran flexion was 0-100 degrees and extension was 90-7 or 90-5 degrees. Additionally, the Veteran had no another factors of the disability not associated with limitation of motion. Dr. M. provided that the Veteran did not have muscle atrophy, no history of recurrent subluxation or lateral instability, no recurrent effusion, and no joint instability. The Veteran also had a negative Lachman test, negative posterior drawer test, and negative medial and lateral instability tests. It was noted that the Veteran used a cane. The private physician also noted that the Veteran did have degenerative arthritis and that there was objective evidence of crepitus. He identified that the Veteran would have pain with prolonged walking and standing and would likely have issues lifting due to knee pain. The physician also pointed out that he had only saw the Veteran twice for issues related to the Veteran's right knee. In June 2016, the Veteran underwent a VA examination of his right knee. The Veteran reported no flare-ups of his knee, but reported functional loss, as he stated that he was unable to ambulate, squat, kneel, or climb stairs due pain in his knee joints. The examiner noted that the Veteran's range of motion of his right knee was abnormal with a flexion of 0-100 degrees and an extension of 100-0 degrees, but the abnormal range of motion did not contribute to functional loss. The examiner noted pain with weight bearing and localized tenderness or pain of palpation of the joint, as the Veteran verbalized pain and moaned during passive range of motion testing. The Veteran was able to perform repetitive use testing with no additional functional loss or range of motion. The examiner found the examination medically consistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner noted that the Veteran did have reduced muscle strength, but no ankylosis of the right knee. No history of joint instability, recurrent subluxation, and lateral instability was reported. Normal Lachman test, normal posterior instability test, normal medial instability, and normal lateral instability were noted. The examiner noted that the Veteran did have a meniscus condition, as the Veteran reported frequent episodes of pain. The examiner noted the Veteran used a cane and knee brace. Radiographical studies confirmed that the Veteran had degenerative or traumatic arthritis of the right knee. The examiner also noted that the Veteran would have difficulty kneeling and squatting, with prolonged ambulation, on weight bearing, and with prolonged sitting due to pain. In November 2016, the Veteran was afforded another VA examination related to his right knee disability. The Veteran reported no flare-ups of his knee, but reported chronic right knee pain. The examiner noted that the Veteran's range of motion of his right knee was abnormal with a flexion of 0-85 degrees and an extension of 90-0 degrees, but the abnormal range of motion did not contribute to functional loss on its own. The examiner noted pain on flexion and with weight bearing. Moreover, the examiner observed localized tenderness, or pain on palpation of the joint. Objective evidence of crepitus was found. The Veteran was able to perform repetitive use testing with no additional functional loss, or range of motion due to pain. The examiner noted that the Veteran had normal muscle strength, but no ankylosis of the right knee. No history of joint instability, recurrent subluxation, and lateral instability was reported. Normal Lachman test, normal posterior instability test, normal medial instability test, and normal lateral instability test were noted. The examiner noted that the Veteran did have a meniscus condition. Radiographical studies confirmed that the Veteran had degenerative or traumatic arthritis of the right knee. The examiner found that the Veteran's right knee did limit his functional capabilities in a limited matter. Furthermore, the examiner provided that the Veteran should limit heavy duty lifting and excessive walking or bending, but light duty or sedentary work was not prohibited. In April 2017, the Veteran was afforded another VA examination related to his right knee disability. The Veteran reported no flare-ups of his knee, but reported chronic right knee pain, the inability to squat, and difficulty walking, driving, and getting out of bed. The examiner noted that the Veteran's range of motion of his right knee was abnormal with flexion of 10-115 degrees and extension of 115-10 degrees, but the abnormal range of motion did not contribute to functional loss on its own. The examiner noted pain on flexion and extension. Moreover, the examiner observed localized tenderness or pain of palpation of the joint, specifically mild lateral tenderness or pain on palpation of the joint. No objective evidence of crepitus was noted. The Veteran was able to perform repetitive use testing with no additional functional loss or range of motion. The examiner found the examination medically consistent with the Veteran's statements describing functional loss with repetitive use over time, but was unable to state whether pain, weakness, fatigability, or incoordination significantly limited the functional ability with repeated use over time because the Veteran was not examined after prolonged use. The examiner noted that the Veteran had normal muscle strength, but no ankylosis of the right knee. No history of joint instability, recurrent subluxation, or lateral instability was reported. Normal Lachman test, normal posterior instability test, normal medial instability test, and normal lateral instability test were noted. The examiner documented moderate right crepitus, mild lateral TTP, and mild swelling. Moreover, the examiner observed that the Veteran had pain with non-weight bearing, but that it did not result in or cause functional loss, pain with passive range of motion, nor result in, or cause, functional loss. He had pain with weight bearing, but it did not result in or cause functional loss. The examiner noted that the Veteran reported use of a right knee brace, cane and walker. Radiographical studies confirmed that the Veteran had degenerative or traumatic arthritis of the right knee. In June 2017, the Veteran was afforded a VA examination related to his right knee disability. The Veteran reported no right knee flare-ups, and no functional loss or impairment. The examiner noted that the Veteran's range of motion of his right knee was abnormal with flexion of 0-110 degrees and extension of 110-0 degrees, but that abnormal range of motion did not contribute to functional loss on its own. The examiner noted pain, but no pain with weight bearing. Moreover, the examiner observed localized tenderness, or pain on palpation of the joint, specifically mild pain on the medial side. No objective evidence of crepitus was noted. The Veteran was able to perform repetitive use testing with no additional functional loss or range of motion. The examiner noted that the Veteran had normal muscle strength, but no ankylosis of the right knee. No history of joint instability, recurrent subluxation, or lateral instability was reported. Normal Lachman test, normal posterior drawer test, normal medial instability testing, and normal lateral instability testing, were also noted. The examiner noted that the Veteran did not have a meniscus condition. The examiner noted that the Veteran reported use of a right knee brace. Radiographical studies confirmed that the Veteran had degenerative or traumatic arthritis of the right knee. With regard to the right knee, there was no pain with non-weight bearing, no pain with passive range of motion, and no pain with weight bearing. Based on a review of the evidence of the record, the Board finds that the Veteran's service-connected right knee disability has been correctly rated as 10 percent disabling from June 22, 2009 to the present. The Board finds that higher evaluations cannot be assigned under Diagnostic Codes 5256, 5257, 5259, 5260, 5261, or 5262. With regard to Diagnostic Code 5256 (knee ankylosis) and 5257 (recurrent subluxation or lateral instability), there is no objective evidence that the Veteran suffers from ankylosis or recurrent subluxation or lateral instability. During the VA examinations in March 2011, May 2017, June 2017, November 2017, April 2017, and June 2017 testing maneuvers were performed and disclosed no such instability. Diagnostic Code 5259 is not applicable because there is no objective evidence of symptomatic removal of semilunar cartilage. The Board notes the Veteran reported the use a knee brace, walker, and cane during this period, despite the advisement of the March 2011 VA examiner to focus on physical therapy and discontinue the use of assistive devices. However, the Board points out that the use of an assistive device, such as a knee brace, walker or cane, does not, by itself denote knee instability. With regard to Diagnostic Codes 5260 (limitation of flexion) and 5261 (limitation of extension), the Veteran cannot be assigned a higher evaluation under either aforementioned diagnostic code. The Board notes that the Veteran did register extension limited to 10 degrees in his April 2017 VA examination, however, such limitation is contemplated for no higher than a 10 percent rating. While the record reflects that the Veteran was awarded a ten percent rating by analogy to DC 5257, for recurrent subluxation or lateral instability, under 38 C.F.R. § 4.71, Diagnostic Codes 5299- 5257, the Board finds that the service-connected disability at issue is more appropriately rated under DC 5261 for limited and painful motion, as the clinical evidence has consistently demonstrated no objective evidence of knee instability. Without demonstration of extension limited to 15 degrees or more, a higher rating cannot be assigned for limitation of extension. Accordingly, a higher rating under Diagnostic Code 5261 is not appropriate in this matter. The Veteran's right knee flexion has been shown to be limited between 90 and 115 degrees. Without demonstration of flexion limited to 60 degrees or less, a compensable rating cannot be assigned for limitation of flexion. Accordingly, a separate additional rating based on limitation of flexion is not appropriate in this matter. See 38 C.F.R. § 4.71a, Diagnostic Code 5160. The evidence reflects that the Veteran's right knee was positive for osteoarthritis combined with evidence of pain and limitation of motion, including on X-ray examination in August 2016. Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint under the appropriate diagnostic codes for the specific joint or joints involved. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Although the evidence reflects that the Veteran has degenerative joint disease in his right knee, he is not entitled to an additional separate rating under Diagnostic Code 5003 because his symptoms of pain and limitation of motion are already compensated through his current rating under Diagnostic Code 5261. See 38 C.F.R. § 4.14 (stating that the rating of the same disability or its manifestations under various diagnoses is to be avoided). Thus, a rating pursuant to Diagnostic Code 5003 is not warranted in this case. In conclusion, the Board finds that a higher disability evaluation is not warranted for the Veteran's service connected right knee disability from June 22, 2009 to present. III. Entitlement to service connection for a back disability, to include as secondary to service-connected right knee disability. The Veteran contends that his claimed low back disability is related to his service, or was caused or aggravated by his service-connected right knee disability. To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310(a), (b). In addition, for veterans who have served 90 days or more of active service after December 31, 1946, there is a presumption for certain chronic diseases, to include arthritis, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." If there is not sufficient evidence that the currently diagnosed chronic disease was chronic in service or within presumptive period, a veteran may still be entitled to presumptive service connection if continuity of symptomatology is demonstrated. 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic as per 38 C.F.R. § 3.309 (a)). The medical and lay evidence of record clearly establishes that the Veteran currently suffers from lumbar spondylosis (degenerative joint disease). See April 2017 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. Therefore, the record clearly establishes the first element of service connection, a current disability. Turning to the second element of service connection, in-service disease or injury, the Veteran's service treatment records (STRs) note an in-service low back strain after lifting of a missile in April 1985. However, a follow-up note in April 1985 provided that the Veteran's back was without problem. The Veteran's separation examination in March 1985 contained no notation of continuing back issues. The Board finds that the second element of service connection is met because even though it appears from the Veteran's STRs that the Veteran's low back strain was resolved during service, the Veteran did suffer a back strain during active service. Regarding secondary service connection, the Board notes that the Veteran is service-connected for right knee disability, as discussed above. The Board notes that the Veteran is additionally service-connected for right ankle disability, and right forearm burn residuals. The Veteran has not asserted that the low back disability at issue is proximately due to or chronically aggravated by the service-connected right forearm burn or right ankle disability. As such, the Board's consideration is limited to the Veteran's contention with regard to the service-connected right knee disability. The question for the Board is whether the Veteran's claimed low back disability is related to his service, or was caused or aggravated by service-connected right knee disability. The Board finds that the preponderance of the most probative evidence is against a finding that the Veteran's low back disability is related to his military service, or was caused or aggravated by service-connected right knee disability. The Veteran's VA medical treatment records detailed a history of chronic back pain complaints, beginning in August 2007. Radiographic studies completed related to the Veteran's back showed degenerative joint disease (DDD) of the spine starting in July 2009. The Veteran's private medical records also detailed recent treatment of chronic low back pain. The Veteran's private physician, Dr. B., provided in a February 2017 private treatment record that the Veteran reported a history of back pain. Dr. B. found that the Veteran displayed a moderate diminished range of motion of the lower back secondary to pain. Dr. M., who began treating the Veteran in April 2017, provided in an April 2017 private medical treatment note that the Veteran's pain in his right knee causes the Veteran to walk with a cane which caused the Veteran's subsequent low back issues. The Veteran was afforded VA examinations in March 2011, December 2015, and April 2017 to determine whether his claimed low back disability is related to his military service, or was caused or aggravated by his service connected right knee. The March 2011 examiner concluded that the Veteran's, "complaints related to his back are unrelated to military service or to his one-time acute lumbar sacral strain." The examiner pointed out that the Veteran's in-service low back strain was resolved and was noted to have a normal spine upon discharge. The examiner provided that the Veteran has had multiple Waddel signs of global numbness of the right foot, global pain radiating from the back down to the leg, and spine pain without tenderness or reactive muscle spasm to the spinal muscles. The December 2015 VA examination provided that the Veteran had a diagnosis of degenerative arthritis of the spine. The examiner opined that the Veteran's low back condition was less likely than not proximately due to or the result of the Veteran's service connected right knee. The examiner provided that the Veteran had normal space alignment of bilateral knees, and the MRI of the Veteran's lumbar spine noted degeneration as well with no disc protrusion. The examiner pointed to the Veteran's post military occupations, as a furniture loader and tire installer, which required heavy lifting, and the Veteran's increased body mass index, as the source of the Veteran's back disability. The examiner was unable to provide a baseline of severity because the Veteran did not have any low back complaints in-service or in the presumptive period. The examiner also cited a neurosurgery note that provided a diagnosis of degenerative disc disease of the spine and noted, "little worse with mild bulge no significant defects nor stenosis at any level." Therefore, the Veteran was unable to provide an opinion as to whether the Veteran's low back condition was aggravated by the Veteran's service connected right knee because he was unable to establish a baseline. The April 2017 examiner provided that, " the spondylosis diagnosis and etiological attribution are more than likely related to degenerative changes associated with aging and post military labor intensive occupational history involving automotive mechanic and tire laborer, and therefore this diagnosis should be considered a new and separate condition unrelated to the in-service back injury." Moreover, the examiner explained that spondylosis is a natural progressive process of aging that causes degenerative changes in the intervertebral discs. The Veteran's radiographic studies upon review by the examiner showed evidence of widespread spondylosis evidenced by calcification with the loss of disc resilience, enlarged facet joints, and the thickening of the support ligaments of the back in an attempt to stabilize the spine. All of which are medical evidence of spondylosis. Further, the examiner noted that the Veteran does have a bulging disc that causes some central canal stenosis, which can cause radicular pain. The examiner addressed the in-service low back sprain by opining that, "spinal strain, such as diagnosed during service, results from trauma causing and stretching or tearing of muscles, tendons, ligaments, or fascia, but not vertebrae, and therefore this diagnosis should be considered a new and separate condition unrelated to the in-service back injury." The April 2017 examiner also opined that it is not least as likely as not that the Veteran's current low back disability is caused or permanently aggravated beyond its normal progression by the Veteran's service connected right knee. The examiner found no medical evidence of a significant gait abnormality or left length discrepancy prior to the onset of the Veteran's spondylosis, making gait an unlikely cause of the low back disability, as identified by the Veteran's private physician. Therefore, the examiner concluded without objective evidence of a significant gait abnormality caused by the service connected right knee, the service connected right knee was unlikely to be the cause of the current spine condition. The examiner provided further that the radiographic evidence showed that the Veteran's right knee degenerative changes started in 2012 with the low back condition starting in 2009, therefore the back condition preceded the knee condition, thus it was very unlikely that the current lumbar spine condition was etiologically caused by the service connected right knee. The examiner also opined that degenerative joint disease is a chronic condition that tends to progressively worsen over time with the natural aging process and/or repetitive injury, but the current radiographical evidence showed only mild to moderate spondylotic changes, thus the Veteran's condition was within the normal progression, and there was no medical evidence that supported a conclusion of an abnormal progression of the Veteran's low back disability due to his service connected right knee. When assessing the probative value of a medical opinion, the access to the claims file and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean, 13 Vet. App. at 448-9. Claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for medical opinions. A medical opinion that contains only data and conclusions has reduced probative weight. Further, a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez, 22 Vet. App. at 304. In this case, as to the issue of whether the Veteran's low back disability is secondary to his service-connected right knee disability, or related to his military service, the Board finds that the April 2017 VA examination report is the most probative evidence of record as it was definitive, based upon a complete review of the Veteran's entire claims file, in consideration of the Veteran's reported history, contemporaneous physical evaluation of the Veteran, and pursuant to the Board's remand instructions. Furthermore, the examiner provided a complete and thorough rationale in support of his opinion. The examiner based his opinion on review and evaluation of the record; and he provided rationale for his findings. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board fully acknowledges the private opinion from the Veteran's private physician, Dr. M., which stated that the Veteran's service connected right knee resulted in abnormal gait, which placed undue stress on the Veteran's back. The April 2017 VA examiner did not agree with the assessment by Dr. M. The examiner cited that there was no objective medical evidence of an abnormal gait or left length discrepancy prior to the onset of the Veteran's spondylosis, as suggested by Dr. M. Therefore, the Board finds the April 2017 examination as more persuasive than the private opinion provided by Dr. M. Regarding the presumption in favor of chronic diseases and the continuity of symptomatology, the Board notes that the Veteran has been diagnosed with lumbar spondylosis with degenerative joint disease. For VA purposes, diagnosis of degenerative joint disease is a chronic disease, thus warranting consideration under 38 C.F.R. § 3.309(a). However, in order for the presumption under 38 C.F.R. § 3.309 to apply the disability must manifest to a compensable degree within one year of discharge from service. However, in this case the Veteran did not report any complaints of back pain until at least twenty (20) years after service, which is more than one year after discharge from service. See 38 C.F.R. § 3.309. Moreover, the Veteran did not receive a diagnosis for a low back disability until 2009, as well. Furthermore, neither does the Veteran show continuity of symptomatology with regard to his low back disability due to the length of time between discharge and complaints of back problems. Id.; Walker, 708 F.3d at 1377. Since the Veteran's degenerative joint disease did not manifest to a compensable degree within one year of discharge from service and there is no evidence of a chronic disability in service, the presumption in favor of chronic diseases is not warranted in this case. Walker, 708 F.3d 1331; 38 C.F.R. §§ 3.303 (b), 3.307, 3.309(a). The Board acknowledges the statements provided by the Veteran and his spouse concerning low back pain. All of which the Veteran and his spouse are competent and credible to report and entitled to a degree of probative weight. However, all of the Veteran's statements of pain and symptomology pertain to the determination of whether a current disability exists. The Board acknowledges that the Veteran has a low back disability, and whether or not the Veteran has a current disability is not at issue here. Rather, for consideration is whether it is at least as likely as not that there is a nexus between his low back disability and his military service, or his service-connected right knee disability. The Board has considered the Veteran's contention that his low back disability is due to service, and/or caused, or aggravated by his service-connected right knee disability. In this regard, the Veteran is competent to report the symptoms that he experienced and his history of treatment. See Charles v. Principi, 16 Vet. App. 370, 374- 75 (2002). However, the Veteran, as a lay person, has not been shown to have the medical knowledge and/or expertise so as to be deemed competent to make a medical conclusion as to a complex medical diagnosis and/or opinion regarding the etiology of a back disability. Given the Veteran's lack of demonstrated medical expertise, the Board finds that the opinion of the April 2017 VA examiner, a medical professional, to be the most probative evidence of record as to the current nature and etiology of his claimed low back disability, to include the relationship between the Veteran's low back disability and his service-connected right knee disability. This opinion ultimately outweighs the Veteran's lay contentions. See Jandreau, 492 F.3d at 1372. (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); see also Layno v. Brown, 6 Vet. App. 465 (1994) (cautioning that lay testimony that the Veteran suffered a particular illness (bronchial asthma) was not competent evidence because matter required medical expertise). Although the Veteran has established a current disability, the preponderance of the evidence weighs against a finding that the Veteran's low back disability is causally related to his service, was manifested within an applicable presumptive period, or caused or aggravated by his service-connected right knee disability. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. §5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102. For these reasons, service connection on a, direct-incurrence basis, to include presumptive direct-incurrence basis, or as proximately due to or chronically aggravated by service-connected disability, is denied. ORDER Entitlement to a compensable initial rating prior to June 22, 2009, or a staged initial rating in excess of 10 percent from June 22, 2009, for service-connected right knee disability, is denied. Entitlement to service connection for a back disability, to include as secondary to service-connected right knee disability is denied. REMAND The Board now turns to the Veteran's claim for entitlement to a TDIU. In a TDIU claim, a total disability rating for compensation may be assigned when the veteran receives less than a total disability rating (less than 100 percent) and is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Regulations provide that if a veteran is service-connected for one disability, it must be rated as 60 percent disabling or more. If a veteran is service-connected for two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (2017). However, VA policy is to grant a TDIU in all cases where service-connected disabilities preclude gainful employment, regardless of whether a veteran satisfies the above percentage evaluations. 38 C.F.R. § 4.16(b) (2017). In such a case, the Board may not assign a TDIU without ensuring that the claim is referred to VA's Director of Compensation Service for consideration of an extraschedular rating under 38 C.F.R. § 4.16(b). Bowling v. Principi, 15 Vet. App. 1 (2001). The rating period for consideration in adjudicating the TDIU claim is from July 2006. Here, during the rating period on appeal the Veteran is service connected for the following disabilities: (1) right knee disability, rated noncompensable prior to June 22, 2009 and 10 percent from June 22, 2009 (with the exception of a period of a temporary total (100 percent) convalescence rating); (2) residuals of burn on the right forearm, rated noncompensable prior to August 22, 2011 and 10 percent from August 22, 2011; and (3) traumatic degenerative joint disease of the right ankle, rated at 10 percent. The combined evaluation for these disabilities was noncompensable prior to June 22, 2009, 10 percent from June 22, 2009 through August 21, 2011, and 30 percent from November 14, 2016 (with the exception of a period of a temporary total (100 percent) convalescence rating). See 38 C.F.R. § 4.25 (Combined Ratings Table). Thus, the Veteran does not meet the schedular criteria for consideration of a TDIU at any time during the rating period on appeal. However, the evidence of record, including the Veteran's work history and education indicates that the Veteran's disabilities, specifically his service-connected right knee disability, may interfere with his continued employment in the fields in which he has training and experience. The Veteran reported in his Social Security Administration (SSA) records working as a welder, cardboard cutter, mechanic, retail clerk, and car detailer. The highest level of education achieved by the Veteran was receiving his GED in 1982. VA examiners have noted that the Veteran's service-connected right knee disability restricts the Veteran to sedentary duty, however, based on the Veteran's education and work history that restriction may render the Veteran unemployable. Thus based on the evidence of record, the Board concludes that the facts of this case meet the criteria for submission of the Veteran's claim to VA's Director of Compensation Service for consideration of entitlement to a TDIU. Therefore, a remand is warranted at this time. Accordingly, the case is REMANDED for the following actions: 1. Send VA Form 21-4192 to the Veteran's last known employer after eliciting any information or authorization required from the Veteran. All efforts to obtain such records must be documented in the electronic claims file. If a negative response is received from the employer, document such in the electronic claims file and provide the Veteran with appropriate notice. 2. Refer the claim to VA's Director of Compensation Service for consideration of whether a TDIU on an extraschedular basis is warranted. Include a full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. See 38 C.F.R. § 4.16(b) (2017). 3. Following completion of the actions requested above, readjudicate the issue of entitlement to a TDIU. If the benefit sought remains denied, provide a Supplemental Statement of the Case to the Veteran and his representative, and afford an appropriate period in which to respond. Then, return the appeal to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs