Citation Nr: 20023976 Decision Date: 04/07/20 Archive Date: 04/07/20 DOCKET NO. 12-29 794 DATE: April 7, 2020 ORDER Entitlement to an initial compensable rating for residuals of a left inguinal hernia is denied. Entitlement to service connection for a left ankle condition, to include as secondary to service-connected right ankle sprain, is denied. Entitlement to service connection for a bilateral hip condition, to include as secondary to service-connected right ankle sprain, is denied. Entitlement to service connection for a bilateral knee condition, to include as secondary to service-connected right ankle sprain, is denied. REMANDED Entitlement to service connection for thoracic outlet syndrome is remanded. Entitlement to an initial rating in excess of 10 percent for a right ankle sprain is remanded. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is remanded. FINDINGS OF FACT 1. Throughout the appellate period, the Veteran’s residuals of a left inguinal hernia have manifested as small, reducible, or without true hernia protrusion. 2. The Veteran’s left ankle condition is not secondary to his service-connected right ankle sprain and is not otherwise related to an in-service injury or disease. 3. The Veteran’s bilateral hip condition is not secondary to his service-connected right ankle sprain and is not otherwise related to an in-service injury or disease. 4. The Veteran’s bilateral knee condition is not secondary to his service-connected right ankle sprain and is not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for residuals of a left inguinal hernia have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.3, 4.6, 4.7, 4.10, 4.114 Diagnostic Code (DC) 7338 (2018). 2. The criteria for service connection for a left ankle condition, to include as secondary to his service-connected right ankle sprain, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018). 3. The criteria for service connection for a bilateral hip condition, to include as secondary to his service-connected right ankle sprain, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018). 4. The criteria for service connection for a bilateral knee condition, to include as secondary to his service-connected right ankle sprain, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1988 to May 1991. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a June 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in March 2014. A transcript of the hearing is associated with the electronic claims file. The Board issued two prior remands in this case in January 2015 and July 2017. Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran’s hernia residuals are evaluated under DC 7338 for hernia, inguinal. Pursuant to DC 7338 a noncompensable rating is warranted for small, reducible, or without true hernia protrusion and not operated, but remedial hernias. A rating of 10 percent is granted for postoperative recurrent, readily reducible and well supported by truss or belt. A rating of 30 percent is warranted for small, postoperative recurrent, or unoperated irremediable, not well supported by truss, or not readily reducible hernias. Finally, a 60 percent rating is warranted for large, postoperative, recurrent, not well supported under ordinary conditions and not readily reducible, when considered inoperable. 1. Entitlement to an initial compensable rating for residuals of a left inguinal hernia. The Veteran was granted service connection for residuals of a left inguinal hernia status post herniorrhaphy effective June 29, 2010, evaluated at 0 percent. The RO based this evaluation on an April 2011 VA examination wherein the examiner noted “I have not seen any kind of tenderness to the left inguinal region incision mark which is secondary to his left-sided herniorrhaphy. He has no evidence of lump or swelling to his left inguinal region on coughing. There is no evidence of recurrence of the hernia to his left inguinal region. He has no evidence of using a truss or belt. There is no evidence of neoplasm on palpation.” The Veteran appealed this noncompensable rating up to the Board and in a January 2015 remand, the Board instructed the RO to provide the Veteran with another VA examination for his hernia residuals. The Veteran was given this exam in August 2015. Here, the examiner noted “Today’s examination shows there is no objective evidence of recurrent or current left inguinal hernia. There is no objective evidence of recurrent left inguinal hernia on today’s examination.” The examiner also noted that there was no indication for a supporting belt and no functional impairment caused by the hernia residuals. As noted above, a noncompensable rating for inguinal hernias is warranted for small, reducible, or without true hernia protrusion and not operated, but remedial hernias. In order to be rated at 10 percent the Veteran would need to show his hernia was postoperative recurrent, readily reducible and well supported by truss or belt. As the Veteran does not require a support belt or truss and his residuals cause no functional impairment, a noncompensable rating is warranted. Accordingly, entitlement to an initial compensable rating for residuals of the left inguinal hernia is denied. Additionally, the Board notes the Veteran’s September 2015 correspondence indicating that he is not trying to gain a disability rating for his actual hernia, but instead for his infertility. He speculates his “spermidal tube was either cut or damaged during [his] surgery.” While no formal claim for service connection for infertility has been filed, as part of the January 2015 remand, the Board instructed the RO to obtain an opinion as to the Veteran’s fertility. The August 2015 VA examiner opined that based on the Veteran’s current diagnoses and risk factors, it was at least as likely as not that the Veteran has infertility. However, the examiner also opined that the Veteran’s infertility was neither caused by nor aggravated by his history of unilateral inguinal hernia. As his rationale, the examiner provided “Evidence shows the Veteran had only a left inguinal herniorrhaphy. Sperm formation normally occurs in each of the two testes. There is no evidence in the record that the inguinal hernia affected the ability to produce or transport the sperm from the testes to the penis. It is known that men are capable of fathering children even after removal of one testis. In [the Veteran’s] case, he had a hernia repair on the left side and there is no evidence that the left side or the right side testis were affected. In the Veteran’s case, it is more likely that the other risk factors of hypogonadism, obesity and diabetes are related to any undiagnosed infertility then would a remote history of unilateral hernia repair.” The Board finds the opinion is adequate as it is based on consideration of the Veteran’s contentions, review of the file, and sound medical principles. While the Veteran is competent to describe symptoms observable to his senses, he is not competent to determine the cause of his infertility as this requires specialized medical training to understand the complexities of the genitourinary and reproductive systems. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The medical expert has determined that the Veteran’s theory is unfounded. Thus, the Veteran is not entitled to a higher rating on this basis. Service Connection Generally, to establish service connection a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315–16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated (worsened in severity beyond its natural progress) by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 448–49 (1995). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336–37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 2. Entitlement to service connection for a left ankle condition, to include as secondary to service-connected right ankle sprain. The Veteran’s left ankle has been diagnosed with a lateral collateral ligament sprain. As such, a current disability has been established. The Veteran contends that his left ankle condition is secondary to his service-connected right ankle sprain. However, the preponderance of the evidence is against the finding that his left ankle condition was caused or aggravated by his right ankle sprain. The Board notes that at the Veteran’s initial VA examination for his right ankle in April 2011, the examiner noted “The Veteran denies left ankle injury or pain while he was in active service.” The Veteran was given another VA examination for his ankle in November 2012. By this time the Veteran was claiming service connection for his left ankle condition as secondary to his service-connected right ankle. However, the examiner noted that the Veteran reported no specific injury to his left ankle, just that he “began having pain in his left ankle about 10 years ago. Reports he had to compensate with his left ankle due to injury to the right ankle. Reports no medical evaluation or treatment for his left ankle.” The examiner did not diagnose any left ankle condition and noted that the Veteran gave limited effort in the range of motion and strength testing portions of the examination. X-rays showed no fracture or bony subluxation of the left ankle, with ankle joint space intact and no bony abnormality and no significant degenerative changes. Ultimately, the examiner opined that it was less likely than not that the Veteran’s claimed left ankle condition was caused by his service-connected right ankle sprain. As his rationale, the examiner noted “On examination the left ankle has no edema or deformity. The Veteran did not complain of pain on light palpation of the whole left ankle. The Veteran was able to ambulate with a steady gait and has a slight limp concerning his right ankle. The Veteran has no specific diagnosis concerning his left ankle other than subjective complaints of constant pain and weakness.” The Board finds this opinion to be supported by the objective medical evidence and thus entitled to significant weight. The Veteran appealed this issue up to the Board providing several articles explaining a possible connection between his right and left ankle conditions. In the January 2015 Board remand, the RO was instructed to provide the Veteran with another examination for his left ankle and to have the examiner review the Veteran’s provided articles in making an opinion. The Veteran was given another VA examination in August 2015, wherein the examiner opined that it was less likely than not that the Veteran’s left ankle condition was caused or aggravated by his service-connected right ankle sprain. Specifically, the examiner noted “Review of the Veteran’s STR shows evidence that there was no left ankle condition during active duty. A compensation and pension examination dated 04/28/2011 shows that the examiner did not do a left ankle exam, stating, ‘On reviewing the Veteran’s service medical record, he has no evidence of left ankle injury or complaint while he was in active service. Therefore, I have not examined his left ankle joint. The Veteran also denies left ankle pain or any kind of disability while he was in service.’ By his own statement during today’s examination, the Veteran stated ‘My left ankle has been developing pain for the past 20 years. I’ve sprained my left ankle before in the military, but I never went to sick call. I just iced it down and put an ACE bandage.’ The record does not show evidence of a biomechanical or pathophysiological process originating from the right ankle that caused or aggravated a left ankle condition. Evidence does not support the causation of a left ankle condition due to a right ankle condition nor is there evidence that a left ankle condition was aggravated by a right ankle condition. The articles submitted by the Veteran, in general, show a correlation between function of other joints due to chronic ankle instability, however, the articles do not conclude conditions such as sprain/strain are caused by or aggravated by chronic ankle instability. On examination, decreased range of motion without pain of the left ankle was observed. Radiographs taken of the left ankle for this examination were negative. This examiner diagnosed a chronic strain of the left ankle based on this examination.” Once again, the examiner listed the articles provided by the Veteran which he reviewed and summarized as part of his opinion. The Board finds this opinion to be thorough and well-supported by the record, entitling it to significant weight. The Board again notes the Veteran’s complaints about this examiner, however as noted above, the detailed rationale behind the examiner’s opinions weigh in favor of his competence. Moreover, the prior November 2012 VA examiner also offered a negative nexus opinion. Finally, the record does not contain any positive medical nexus opinions wherein the Veteran’s left ankle condition is found to be caused or aggravated by his service-connected right ankle sprain. The only other opinion in this matter comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on these matters possess a level of expertise that a layperson simply does not possess. The Veteran also recently claimed that he sprained his left ankle in service. This current statement is inconsistent with earlier statements in which the Veteran maintained that he did not sustain a left ankle injury in service and service treatment records contemporaneous to the Veteran’s service. The Board finds that the evidence is not credible that the Veteran sustained a left ankle injury in service. Accordingly, entitlement to service connection for a left ankle condition, to include as secondary to his service-connected right ankle sprain, is denied. 3. Entitlement to service connection for a bilateral hip condition, to include as secondary to service-connected right ankle sprain. The Veteran has a current diagnosis of osteoarthritis of the bilateral hips. Thus, a current disability has been established. The Veteran contends that his bilateral hip condition is secondary to his service-connected right ankle sprain. However, the preponderance of the evidence is against the finding that the Veteran’s bilateral hip condition was caused or aggravated by his right ankle sprain. The Veteran first had a VA examination for his bilateral hips in November 2012. Here, the examiner diagnosed minimal degenerative changes and noted that the Veteran reported no specific injury to his hips, but reports pain in both hips for 20 years or more due to him having to compensate with his hips for his right ankle. The examiner provided “Review of the medical records at the Beckley VAMC has documentation of bilateral hip x-rays with report of minimal degenerative changes on 9/21/2011 with repeat of the right hip x-ray on 9/12/2012 with same impression. On examination the Veteran offered limited effort in ROM and muscle strength testing due to subjective complaints of pain and weakness. The Veteran declined to try & cross his legs at his knees due to reported weakness in his legs that he cannot lift them. The Veteran did complain of pain on light palpation of the hips. The Veteran was able to ambulate with a steady gait and has a slight limp concerning his right ankle. Review of medical literature indicates that risk factors for DJD are aging, occupation, trauma, and repetitive small insults over time. Osteoarthritis is a normal result of aging. It is also caused by ‘wear and tear’ on a joint. Being overweight increases the risk of OA in the hip, knee, ankle, and foot joints because extra weight causes more wear and tear. It is less likely than not that the Veteran’s minimal degenerative changes of bilateral hips is caused by his service connected right ankle sprain. The minimal degenerative changes in the bilateral hips would be consistent for his age, weight and occupation as an auto mechanic.” The Board finds this opinion to be well supported by the record, entitling it to significant weight. The Veteran also appealed this issue up to the Board providing several articles regarding ankle instability and postural control as well as hip kinematics. Thus, in the January 2015 remand the Board instructed the RO to provide the Veteran with another VA examination for his bilateral hips and to consider the articles provided by the Veteran when making an opinion for secondary service connection. In August 2015 the Veteran was given this examination. The examiner noted reviewing the Veteran’s electronic file as well as each of the articles provided by the Veteran with regard to ankle instability and the hips. The examiner provided a summary of each article in the rationale section of his opinion. The examiner opined that the Veteran’s osteoarthritis of the hips was not caused or aggravated by the Veteran’s service-connected right ankle sprain. As rationale he provided “Review of the Veteran’s c-file shows that he is service-connected for a right ankle condition. Review of the post-service record shows the Veteran has been diagnosed with osteoarthritis of the hips and knees. The Veteran has degenerative arthritis, not traumatic arthritis. This condition is related to chronic use, wear and tear and aging. Additionally, current medical literature (www.mayoclinic.org, accessed electronically) shows obesity as a risk factor for the development of arthritis, ‘particularly your knees, hip and spine. Obese people have a higher risk of developing arthritis.’ Review of records shows the Veteran having a BMI as high as 45 in 2014 although he has recently lost quite a bit of weight (recent bariatric surgery in March 2014) and his current BMI is 38. (BMI categories: 19-24 is healthy; 25-29 is overweight; 30-39 is obesity; 40-50 is extreme obesity). The oft-cited but speculative statement that a bad joint causes another joint to be favored which then leads to arthritis is unproven in literature. Neurology consultation notes in December 2012 and in February 2015 do not describe antalgic gait. There is no evidence in the record that the right ankle condition caused osteoarthritis of the hips or knees. There is no evidence in the record that the right ankle aggravated the knee and hip osteoarthritis beyond natural progression. Current medical literature does not support causation of osteoarthritis due to overcompensation, gait alteration and instability.” The Board finds this opinion to be extremely thorough and well-supported by the record, entitling it to significant weight. The Board again notes the Veteran’s complaints about this examiner, however as noted above, the detailed rationale behind the examiner’s opinions weigh in favor of his competence. The fact remains, after considering the Veteran’s contentions and the medical evidence of record, the examiner did not find a probable link between the Veteran’s hips and his right ankle for multi-factorial reasons. While the Veteran was observed to have a slight limp concerning his right ankle, he was otherwise able to ambulate with a steady gait in November 2012, and neurology consultation notes in December 2012 and in February 2015 did not describe an antalgic gait. Importantly, in the examiner’s expert opinion, the pathology/disease process associated with the Veteran’s hips is not consistent with the mechanism of injury claimed by the Veteran. The record does not contain any positive medical nexus opinions with regard to the Veteran’s bilateral hip osteoarthritis and his service-connected right ankle sprain. Instead, both VA examiners opined that the Veteran’s current osteoarthritis of the hips is more likely due to his aging, weight, and 20-year career as an auto mechanic. Thus, the Veteran’s theory has been rendered unfounded as the degenerative changes associated with the Veteran’s hips are not consistent with the mechanism of injury claimed by the Veteran. While the Veteran is competent to describe symptoms observable to his senses, he is not competent to diagnose a hip disability or determine its cause as this requires specialized medical training to understand the complexities of the musculoskeletal system. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Accordingly, entitlement to service connection for a bilateral hip condition, to include as secondary to his service-connected right ankle sprain, is denied. 4. Entitlement to service connection for a bilateral knee condition, to include as secondary to service-connected right ankle sprain. The Veteran has a current diagnosis of osteoarthritis of the bilateral knees. Thus, a current disability has been established. The Veteran contends that his bilateral knee condition is secondary to his service-connected right ankle sprain. However, the preponderance of the evidence is against the finding that the Veteran’s bilateral knee osteoarthritis was caused or aggravated by his right ankle sprain. The Veteran was first given a VA examination for his bilateral knees in November 2012. Here, the examiner diagnosed the Veteran with minimal degenerative changes of the bilateral knees. He noted that the Veteran reported no medical evaluation or treatment for his knees during military service, but that he began to have pain in both knees about 20 years ago due to compensating for his right ankle with his knees. The examiner opined that the Veteran’s bilateral knee condition was less likely than not proximately due to or the result of his service-connected right ankle sprain. As rationale the examiner provided “Review of medical records at the Beckley VAMC has documentation of bilateral knee x-rays with report of minimal degenerative changes on 10/17/2012. On examination the Veteran offered limited effort in ROM and muscle strength testing due to subjective complaints of pain and weakness. The Veteran did not complain of pain on light palpation of the knees. The Veteran was able to ambulate with a steady gait and has a slight limp concerning his right ankle. Review of medical literature indicates that risk factors for DJD are aging, occupation, trauma, and repetitive small insults over time. Osteoarthritis is a normal result of aging. It is also caused by ‘wear and tear’ on a joint. Being overweight increases the risk of OA in the hip, knee, ankle, and foot joints because extra weight causes more wear and tear. It is less likely than not that the Veteran’s minimal degenerative changes of bilateral knees is caused by his service connected right ankle sprain. The minimal degenerative changes in the bilateral knees would be consistent for his age, weight and occupation as an auto mechanic.” The Board finds this opinion to be well-supported by the record, entitling it to significant weight. The Veteran also appealed this issue up to the Board providing articles regarding the local and global effects of ankle instability. Thus, in the January 2015 remand the Board instructed the RO to provide the Veteran with another VA examination for his bilateral knees and to consider the articles provided by the Veteran when making an opinion for secondary service connection. In August 2015 the Veteran was given this VA examination. The examiner noted reviewing the Veteran’s electronic file as well as each of the articles provided by the Veteran with regard to ankle instability and its effects. The examiner provided a summary of each article in the rationale section of his opinion. The examiner opined that the Veteran’s osteoarthritis of the knees was not caused or aggravated by the Veteran’s service-connected right ankle sprain. As rationale he provided “Review of the Veteran’s c-file shows that he is service-connected for a right ankle condition. Review of the post-service record shows the Veteran has been diagnosed with osteoarthritis of the hips and knees. The Veteran has degenerative arthritis, not traumatic arthritis. This condition is related to chronic use, wear and tear and aging. Additionally, current medical literature (www.mayoclinic.org, accessed electronically) shows obesity as a risk factor for the development of arthritis, ‘particularly your knees, hip and spine. Obese people have a higher risk of developing arthritis.’ Review of records shows the Veteran having a BMI as high as 45 in 2014 although he has recently lost quite a bit of weight (recent bariatric surgery in March 2014) and his current BMI is 38. (BMI categories: 19-24 is healthy; 25-29 is overweight; 30-39 is obesity; 40-50 is extreme obesity). The oft-cited but speculative statement that a bad joint causes another joint to be favored which then leads to arthritis is unproven in literature. Neurology consultation notes in December 2012 and in February 2015 do not describe antalgic gait. There is no evidence in the record that the right ankle condition caused osteoarthritis of the hips or knees. There is no evidence in the record that the right ankle aggravated the knee and hip osteoarthritis beyond natural progression. Current medical literature does not support causation of osteoarthritis due to overcompensation, gait alteration and instability.” The Board finds this opinion to be extremely thorough and well-supported by the record, entitling it to significant weight. The Board again notes the Veteran’s complaints about this examiner, however as noted above, the detailed rationale behind the examiner’s opinions weigh in favor of his competence. The fact remains, after considering the Veteran’s contentions and the medical evidence of record, the examiner did not find a probable link between the Veteran’s knees and his right ankle for multi-factorial reasons. While the Veteran was observed to have a slight limp concerning his right ankle, he was otherwise able to ambulate with a steady gait in November 2012, and neurology consultation notes in December 2012 and in February 2015 did not describe an antalgic gait. Importantly, in the examiner’s expert opinion, the pathology/disease process associated with the Veteran’s knees is not consistent with the mechanism of injury claimed by the Veteran. The record does not contain any positive medical nexus opinions with regard to the Veteran’s bilateral knee osteoarthritis and his service-connected right ankle sprain. Instead, both VA examiners opined that the Veteran’s current osteoarthritis of the knees is more likely due to his aging, weight, and 20-year career as an auto mechanic. Thus, the Veteran’s theory has been rendered unfounded as the degenerative changes associated with the Veteran’s knees are not consistent with the mechanism of injury claimed by the Veteran. While the Veteran is competent to describe symptoms observable to his senses, he is not competent to diagnose a knee disability or determine its cause as this requires specialized medical training to understand the complexities of the musculoskeletal system. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Accordingly, entitlement to service connection for a bilateral knee condition, to include as secondary to his service-connected right ankle sprain, is denied. REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 10 percent for a right ankle sprain is remanded. In reviewing the adequacy of the existing VA examination reports, certain range of motion testing must be conducted whenever possible in cases of joint disabilities. 38 C.F.R. § 4.59; Correia v. McDonald, 28 Vet. App. 158 (2016). “[T]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint” Correia, 28 Vet. App. 158. The April 2011, November 2012, and January 2015 VA examinations of the Veteran’s right ankle do not comply with Correia. An additional relevant opinion pertaining to flare-ups was also issued by the Court in Sharp v. Shulkin, 29 Vet. App. 26 (2017). As such, a remand is necessary to afford the Veteran another VA examination for his right ankle sprain. 2. Entitlement to service connection for COPD is remanded. In February 2018 correspondence the Veteran contends that his COPD may have resulted from exposure to asbestos. In July 2019 correspondence the Veteran contends that his COPD may have resulted from exposure to TCE carbon at the Schofield Barracks. He alleges that he was exposed to the chemical for almost two years while on active duty. A review of the Veteran’s military personnel records show he was stationed at Schofield Barracks in Hawaii. The Veteran provided a link to a report from the US Environmental Protection Agency (EPA) on the issue. Accordingly, the Board finds remand is necessary for additional development. 3. Entitlement to service connection for thoracic outlet syndrome is remanded. The Veteran contends that his condition is the result of carrying a heavy rucksack of up to 100 pounds during his active service. The Veteran provided several articles explaining a possible connection between his thoracic outlet syndrome and rucksack carrying. Thus, in the January 2015 remand, the Board instructed the RO to provide the Veteran with an examination for his thoracic outlet syndrome and have the examiner provide an opinion as to its etiology considering the articles provided by the Veteran. In August 2015, the Veteran was given this examination. The examiner explained that he had interviewed and examined the Veteran, as well as reviewed all the pertinent electronic records, and read and considered the articles submitted by the Veteran. The examiner included a complete list of the articles considered and summarized each article in his explanation. Nevertheless, the examiner opined that it was less likely than not that the Veteran’s thoracic outlet syndrome had its onset during the Veteran’s service, to include the carrying of a heavy rucksack. Specifically, the examiner provided “Review of [the Veteran’s] service treatment records (STR) reveals no diagnosis of thoracic outlet syndrome or ‘rucksack paralysis.’ Further scrutiny of the STR reveals no complaints of upper extremity symptoms that could be related to a condition such as thoracic outlet syndrome. Examination of the immediate and moderately distanced post-service period shows it is silent for thoracic outlet syndrome or rucksack paralysis until 2005 when the Veteran is diagnosed with bilateral thoracic outlet syndrome. The records show the Veteran was in active duty from 1988-1991. This examiner was aware of the general physical demands of the US Army infantry solider. This examiner’s knowledge of the more specific physical demands of carrying of equipment by the US Army soldier was enhanced during review of the well-written articles submitted by the Veteran. That the Veteran had to carry heavy loads intermittently during a three year enlistment is not questioned by this examiner. However, evidence also shows that for 20 years post-service, the Veteran worked in a physically strenuous occupation of heavy equipment mechanic. There is evidence that heavy lifting was part of the Veteran’s occupation. In the Veteran[sic], in a written statement found in an application for SSA benefits, stated ‘All day I did these things’ in response to a question regarding ‘Frequently lifting 50 lbs or more, heaviest 100 lbs or more.’” The examiner then reviewed several articles of his own, including an explanation of thoracic outlet syndrome and current medical literature indicating that in 80 percent of cases sufferers of backpack palsy show a full recovery within 9 months. He then provided “Evidence does not support that the Veteran had thoracic outlet syndrome during military service or in the immediate post-service period. There is no evidence that any in-service disease, event or injury, to include carrying a heavy rucksack weighing at least 100 lbs is etiologically related to a thoracic outlet syndrome diagnosed in 2005. There is evidence that the Veteran had a strenuous and physically demanding job for 20 years that required heavy lifting. There is evidence in current occupational medication that repetitive and physically strenuous activity such as heavy lifting can increase the risk for development of thoracic outlet syndrome. There is also evidence in current medical literature that wearing a backpack is not the sole associated factor in the development of thoracic outlet syndrome. Obesity can aggravate thoracic outlet syndrome. … In summary, it is this examiner’s opinion that claimed thoracic outlet syndrome is likely more related to decades as a heavy machinery mechanic than related to military service.” In February 2018 correspondence the Veteran indicated that he had been treated for symptoms for his thoracic outlet syndrome since 1993. The Board finds additional development is necessary. The matters are REMANDED for the following action: 1. Undertake appropriate efforts to verify the Veteran’s claim that he was exposed to asbestos and TCE carbon during his service. For details, see February 2018 and July 2019 correspondence from the Veteran. 2. Contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who treated him from discharge until the present for thoracic outlet syndrome. With any necessary authorization from the Veteran, the RO should attempt to obtain copies of pertinent treatment records identified by the Veteran that have not previously been secured. Any records obtained should be associated with the claims folder. Failures to respond or negative replies should be noted in writing and also associated with the claims folder. 3. Schedule a new examination to evaluate the severity of the Veteran’s service-connected right ankle sprain. The claims folder must be made available to and reviewed by the examiner. The examiner should note in the examination report that the claims folder has been reviewed. All indicated studies, including x-rays should be performed. In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree at which pain begins. The examiner should record the results of range of motion testing for pain on active motion, passive motion, weight-bearing, and non-weight-bearing in light of Correia. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups assessed in terms of the degree of additional range of motion loss. In regard to flare-ups (pursuant to Sharp v. Shulkin), if the Veteran is not currently experiencing a flare-up, based on relevant information elicited from the Veteran, review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding his flares, the examiner is requested to provide an estimate of the Veteran’s functional loss due to flares expressed in terms of the degree of additional range of motion lost, or explain why the examiner cannot do so. [The Board recognizes the difficulty in making such determinations but requests that the examiner provide his or her best estimate based on the examination findings and statements of the Veteran.] 4. Obtain an additional opinion, if possible, from the same VA examiner who completed the Veteran’s August 2015 VA examinations regarding the Veteran’s COPD. The electronic claims file must be reviewed by the examiner, and a note that it was reviewed should be included in the report. As with his prior opinions, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s COPD had its onset during active service. The examiner should consider the argument submitted by the Veteran that his COPD was caused by exposure to TCE carbon at the Schofield Barracks in Hawaii or exposure to asbestos “via the Asbestos glove [he] used every time he used the M60.” The examiner should reconcile this opinion with his prior August 2015 opinion on the issue. A detailed rationale for the opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to mere speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Ruiz, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.