Citation Nr: 20028877 Decision Date: 04/24/20 Archive Date: 04/24/20 DOCKET NO. 19-10 111 DATE: April 24, 2020 ORDER Entitlement to an initial rating in excess of 10 percent for right knee disability with knee joint osteoarthritis is denied. Entitlement to a rating higher than 10 percent for residuals of traumatic brain injury (TBI) for any period is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. Entitlement to service connection for left knee disability with osteoarthritis is denied. FINDINGS OF FACT 1. The Veteran’s right knee disability with knee joint osteoarthritis was not productive of actual or functional flexion limited to 30 degrees, actual or functional extension limited to 5 degrees, even with consideration of additional functional loss due to pain; ankylosis, impairment of the tibia and fibula, or genu recurvatum have not been demonstrated. 2. The Veteran’s residuals of head trauma, have been manifested by mild memory loss, attention, concentration, or executive function, but no objective evidence on testing, occasional disorientation to two or more person, time, place, or situation, mildly impaired visual spatial orientation, three or more subjective symptoms with mild impairment, and one or more neurobehavioral effects with no interference. No facet warrants a rating higher than “1”. 3. The evidence fails to establish that the Veteran is precluded from engaging in substantially gainful employment due to his service-connected disabilities. 4. The preponderance of the evidence fails to establish that the Veteran’s left knee disability is etiologically related to service or aggravated by service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for right knee disability with knee joint osteoarthritis based on limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260. 2. The criteria for a rating in excess of 10 percent for TBI residuals have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.124a, Diagnostic Code 8045. 3. The criteria for TDIU have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.151, 3.155, 3.157, 3.340, 3.341, 3.400, 4.16. 4. The criteria for service connection for left knee disability have not been met. 38 U.S.C. § § 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty in the Navy from February 1978 to January 1991 (honorable) and from February 1991 to June 1992 (dishonorable). This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2018 rating decision of a regional office of Department of Veterans Affairs. In September 2019, the Board remanded the matter for additional development; in that same decision, the Board found TDIU was raised by the record and remanded the issue for further development. Rice v. Shinseki, 22 Vet. App. 447 (2009). Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 1. Entitlement to a rating in excess of 10 percent for right knee disability with knee joint osteoarthritis is denied. By rating action of August 2018, the RO increased the noncompensable evaluation for right knee disability with knee joint osteoarthritis to 10 percent under Diagnostic Codes 5010-5260, effective January 18, 2018, the date of claim. 38 C.F.R. § 4.71a. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5010 evaluates arthritis due to trauma, which is to be rated as degenerative arthritis. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved (here, Diagnostic Codes 5260 or 5261 for the knees). 38 C.F.R. § 4.71a, Diagnostic Code 5010. Under Diagnostic Code 5257, a 10 percent disability rating is assigned for slight recurrent subluxation or lateral instability. A 20 percent disability rating is warranted when there is moderate recurrent subluxation or lateral instability, and a 30 percent disability rating requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Diagnostic Code 5258 provides that a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a maximum 10 percent rating is prescribed for removal of symptomatic semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5260, limitation of flexion of the leg at the knee is rated at 10 percent if limited to 45 degrees, at 20 percent if limited to 30 degrees, and at 30 percent, which is the maximum evaluation available, if limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limitation of extension of the leg at the knee is rated at 0 percent if limited to 5 degrees, at 10 percent if limited to 10 degrees, 20 percent if limited to 15 degrees, at 30 percent if limited to 20 degrees, at 40 percent if limited to 30 degrees, and at 50 percent if extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal range of knee motion is from 140 degrees (on flexion) to 0 degrees (on extension) to. See 38 C.F.R. § 4.71, Plate II. In addition, VA regulations provide that “pyramiding,” or evaluation of the same disability under various diagnoses, is to be avoided. 38 C.F.R. § 4.14. VA has specifically found, however, that limitation of motion of the knee and instability of the knee are not duplicative or overlapping conditions, and that a claimant who has both arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97 (July 1997). Separate ratings must be based on additional disability. Diagnostic Codes 5256, 5262 or 5263 are not for application as there is no evidence of ankylosis, tibia and fibula impairment, or genu recurvatum at any point during the appeal period. Diagnostic Code 5259 also does not apply as there is no evidence of removal of semilunar cartilage. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5259, 5262, 5263. A March 2018 VA contract examination reflects that the Veteran demonstrated normal range of motion; right knee flexion to 140 degrees and extension to 0 degrees. There was evidence of pain on movement, but the examiner found that it does not result in functional loss. Joint stability testing was performed with no evidence of locking, instability, joint effusions, or any episodes of dislocation or subluxation of the right knee. Diagnostic testing confirmed knee joint osteoarthritis affecting both right and left side. In compliance with the September 2019 Board remand, the Veteran was afforded another VA examination in September 2019. On examination, he demonstrated right knee flexion to 115 degrees and extension to 0 degrees. The examiner noted objective evidence of pain on movement. The examiner also noted flexion in weight bearing decreased to 40 degrees. Joint testing was performed with normal findings. The examiner noted the right knee disability functional impact as limited prolong walking. Diagnostic testing confirmed knee joint osteoarthritis affecting both sides. Upon review of the evidence of record, the Board finds that the weight of the evidence is against the finding that manifestations of right knee disability with knee joint osteoarthritis more closely approximate the criteria for a higher rating under Diagnostic Codes 5010-5260. For the entire rating period on appeal, flexion ranged from 40 to 140 degrees, including after consideration of functional loss due to pain. Meaning, at no point has the Veteran been found to have limitation of flexion of the right knee to 30 degrees, as required for a 20 percent rating under Diagnostic Code 5260. Further, as the Veteran has not shown limitation of extension of the right knee, a separate rating under Diagnostic Code 5261 is also not supported. Therefore, the Board finds that the Veteran is adequately compensated by the 10 percent evaluation and a higher rating under Diagnostic Code 5260 is not warranted. The Board has considered whether a higher disability rating is warranted under 38 C.F.R. § 4.40 for functional loss due to pain, and under 38 C.F.R. § 4.45 for functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint. DeLuca v. Brown, 8 Vet. App. 202 (1995). Here, the Board does not doubt that the Veteran’s right knee disability causes symptoms of pain and increased pain with weight bearing and prolonged standing. However, even accounting for additional functional limitation due to such reports of pain, the examination reports summarized above reflect that the right knee disability has not been shown to produce additional functional impairment due to pain or functional loss that would warrant a rating higher. Moreover, the VA examiners in March 2018 and September 2019 noted such symptoms and considered these symptoms in their assessments of the overall severity of the right knee disability. Further, the Veteran’s subjective complaints are contemplated in the 10 percent rating presently assigned under Diagnostic Codes 5010, 5260 for arthritis and limited motion. Thus, the Veteran’s assertions do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. For these reasons, the Board finds that the preponderance of the evidence is against the Veteran’s claim for increased rating in excess of 10 percent for right knee disability with knee joint osteoarthritis. See 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260. Accordingly, the claim must be denied. 2. Entitlement to a rating in excess of 10 percent for TBI residuals is denied. By rating decision of August 2018, service connection was granted for TBI and assigned an initial 10 percent rating from January 18, 2018, the date of application. The Veteran disagrees with his initial evaluation and seeks a 100 percent rating. See Notice of Disagreement dated September 2018. The Veteran’s TBI is evaluated under Diagnostic Code 8045. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Diagnostic Code 8045 recognizes three main areas of dysfunction that may result from TBIs and have profound effects on functioning: cognitive, emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation under listed facets. Each facet shall be assigned a level of impairment, ranging from 1 to 3. The disability rating assigned shall be based on the facet with the highest level of impairment. Id. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In a given individual, symptoms may fluctuate in severity from day to day. Cognitive impairment is to be evaluated under the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. Id. Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, are to be evaluated under the subjective symptoms facet in the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere’s disease, even if that diagnosis is based on subjective symptoms, rather than under the Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified table. Id. Emotional/behavioral dysfunction is to be evaluated under § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. Id. Physical (including neurological) dysfunction is to be evaluated based on the following list, under an appropriate diagnostic code: Motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. Id. The preceding list of types of physical dysfunction does not encompass all possible residuals of TBI. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Each condition should be evaluated separately as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. Id. The table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled total. However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than total, since any level of impaired consciousness would be totally disabling. A 100-percent evaluation should be assigned if total is the level of evaluation for one or more facets. If no facet is evaluated as total, assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. Id. Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, assign a separate evaluation for each condition. Id. Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. Id. Note (3): Instrumental activities of daily living refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one’s own medications, and using a telephone. These activities are distinguished from Activities of daily living, which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. Id. Note (4): The terms mild, moderate, and severe TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning. This classification does not affect the rating assigned under Diagnostic Code 8045. Id. As an initial matter, the Board notes that the Veteran has been separately evaluated and service-connected for unspecified depressive disorder; tinnitus; bilateral hearing loss; migraine headaches; and scars. As such, such symptoms associated with psychiatric disorder, hearing impairment, and headache symptoms have may not be considered in the evaluation of his residuals of TBI, as this would constitute pyramiding. See 38 C.F.R. §§ 4.14, 4.124a, Diagnostic Code 8045 Note(1); Esteban v. Brown, 6 Vet. App. 259 (1994). In March 2018, the Veteran was afforded a VA contract examination for initial evaluation for TBI. This examination was conducted by a Psychiatrist. A level of severity of “1” is assigned for Memory, attention, concentration, executive functions facet as the Veteran reported symptoms consistent with complaints of mild memory loss. A level of severity of “0” is assigned for the Judgment facet based on normal. A level of severity of “0” is assigned for the Social interaction facet as social interaction is routinely appropriate. A level of severity of “0” is assigned for the Orientation facet as always oriented to person, time, place, and situation. A level of severity of “0” is assigned for the Motor activity facet as normal. A level of severity of “0” is assigned for the Visual spatial orientation facet based on normal. A level of severity of “1” is assigned for the Subjective symptoms facet as the Veteran medical record shows that he reported dizzy spells, headaches, and blurred vision. A level of severity of “0” is assigned for the Neurobehavioral effects facet as medical evidence shows no neurobehavior effects. A level of severity of “0” is assigned for the Communication facet as the Veteran’s medical record does not show an impairment in this facet. Based on the level of the highest facet of “1”, a 10 percent rating is assigned. See I-TBI Disability Benefits Questionnaire dated March 2018. The record shows a September 2019 VA examination for TBI residuals. This examination was conducted by a Nurse Practitioner. A level of severity of “1” is assigned for Memory, attention, concentration, executive functions facet as the Veteran reported symptoms consistent with complaints of mild memory loss. A level of severity of “0” is assigned for the Judgment facet based on normal. A level of severity of “1” is assigned for the Social interaction facet as the Veteran reported avoids social situations. A level of severity of “1” is assigned for the Orientation facet as the Veteran reported that he can forget where he is driving. A level of severity of “0” is assigned for the Motor activity facet as normal. A level of severity of “1” is assigned for the Visual spatial orientation facet as the Veteran has experienced disorientation. A level of severity of “1” is assigned for the Subjective symptoms facet as the Veteran reported subjective symptoms of depression and anxiety. A level of severity of “0” is assigned for the Neurobehavioral effects facet as the Veteran reported impulsivity and irritability but do not interfere with workplace or social interaction. A level of severity of “1” is assigned for the Communication facet as the Veteran reported difficulty finding words and staying on topic. Based on the foregoing, a 10 percent rating is assigned as no facet is rated higher than “1” for the appeal period. See R-TBI Disability Benefits Questionnaire dated September 2019. In compliance with the September 2019 Board remand, the Veteran afforded another VA contract examination in January 2020. Notably, this examination was conducted by a Physician in Neurological Surgery. A level of severity of “0” is assigned for Memory, attention, concentration, executive functions facet based on no complaints of impairment. A level of severity of “0” is assigned for the Judgment facet based on normal. A level of severity of “0” is assigned for the Social interaction facet as social interaction is routinely appropriate. A level of severity of “0” is assigned for the Orientation facet as always oriented to person, time, place, and situation. A level of severity of “0” is assigned for the Motor activity facet as normal. A level of severity of “0” is assigned for the Visual spatial orientation facet based on normal. A level of severity of “0” is assigned for the Subjective symptoms facet as evaluation does not show an impairment in this facet. A level of severity of “0” is assigned for the Neurobehavioral effects facet as record shows no neurobehavior effects. A level of severity of “0” is assigned for the Communication facet as the Veteran’s medical record does not show an impairment in this facet. Significantly, the neurosurgeon indicated that the Veteran’s detailed neurologic examination was within normal limits. See R-TBI Disability Benefits Questionnaire dated January 2020. Based on the above objective medical evidence, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a higher rating for TBI residuals. A 10 percent rating is assigned as no facet is rated higher than “1” in any of the ten facets of TBI. In fact, the recent January 2020 conducted by a Neurosurgeon indicates that the Veteran’s neurological examination was within normal limits. Thus, the Veteran is adequately compensated by the currently assigned 10 percent evaluation, and a higher rating is not supported. Accordingly, the claim must be denied. 3. TDIU As will be explained below, the Board finds that competent evidence of record does not show that the Veteran was unable to secure or follow a substantially gainful occupation by reason of his service-connected disabilities, and TDIU is not warranted. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and that, if there are two or more service connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a). Initially, the Board notes that the Veteran met the schedular criteria for TDIU. The Veteran’s service-connected disabilities are unspecified depressive disorder at 70 percent; TBI at 10 percent; right knee disability at 10 percent; tinnitus at 10 percent; noncompensable ratings for bilateral hearing loss, migraine headaches, and scar; with a combined evaluation for compensation at 80 percent from January 18, 2018. Thus, the schedular criteria for TDIU have been met. 38 C.F.R. § 4.16(a). With that said, however, the Board finds that the preponderance of the evidence is against the finding that the Veteran was precluded from engaging in substantially gainful employment solely as a result of his service-connected disabilities, to include based on a single disability. Meaning, the Veteran’s service-connected depressive disorder, TBI, right knee disability, tinnitus, bilateral hearing loss, migraine headaches, and scar alone or the combined effects of all service-connected conditions, do not render him unemployable. VA will grant entitlement to a TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from securing and following “substantially gainful employment” consistent with his education and occupational experience. See 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The central inquiry is, “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The Board observes that the record contains sufficient information of the Veteran’s employment and medical history. In his formal application, the Veteran listed his previous employment was in Auto Sales, and he became too disabled to work in August 2018. See Veteran’s Application for Increased Compensation Based on Unemployability, received in October 2019. Further, he listed depression and memory changes as the reasons he is unemployable. Id. To that end, the Board emphasizes that the objective VA medical opinions and medical evidence weigh against the Veteran’s claim and are found to have great probative value. A May 2018 VA medical opinion shows a psychiatrist noting that the Veteran’s current depression is “due to a compilation of issues. He is alone, isolated and homeless. The veteran is currently unemployed. He is reactively depressed to his current circumstances. His current depressive symptoms do not correlate with is TBI either.” The VA psychiatrist indicated the Veteran’s level as “a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication”. A January 2019 VA treatment record shows that the Veteran was admitted for opiate use disorder. He presented to the emergency room seeking admission for detox and at the time reported “for the past year lost 3 jobs” and that he is “now jobless, homeless and sleeps in his car.” A May 2019 VA psychologist indicated the Veteran’s level as “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation.” A September 2019 VA examiner described the functional impact of the Veteran’s right knee disability as “limited prolonged walking.” There was no other functional impact indicated on the Veteran’s ability to perform any type of occupational task. A September 2019 VA examiner noted the functional impact of the Veteran’s residuals of TBI as “difficulty with timeliness of task completion due to memory and focus”. A recent January 2020 VA examination for TBI residuals showed the VA examiner, a physician in Neurological Surgery, finding that the Veteran’s TBI did not impact his ability to work. In fact, the VA physician specifically indicated that the detailed neurologic examination was within normal limits and that the status of the Veteran’s TBI remained “totally unchanged.” In this regard, a review of the objective evidence of record, taken in total, does not suggest that the Veteran is unable to obtain or maintain substantially gainful employment solely as a result of his service-connected disabilities. The Board emphasizes that the persuasive VA medical opinions and medical evidence weigh against the Veteran’s claim and are found to have great probative value. Specifically, the May 2018 VA psychiatrist, the May 2019 VA psychologist, and January 2020 VA neurosurgeon found that the Veteran’s service-connected disabilities did not appear to be of such severity to render him unable to obtain or maintain. Meaning, he is not precluded from engaging in substantially gainful employment due to his service-connected disabilities and is capable of work consistent with his education and employment background. Indeed, the Board has considered that the Veteran’s lay reports of worsening symptoms which may result in some mild functional limitations, but as indicated by the medical professionals that evaluated the Veteran, his service-connected disabilities of depressive disorder, TBI, right knee disability, tinnitus, bilateral hearing loss, migraine headaches, and scar, do not preclude work entirely. The evidence simply does not establish that the Veteran’s service-connected disabilities, in particular depression and residuals of TBI, alone results in unemployability. As such, TDIU is not warranted in this case. The Board acknowledges that the Veteran is competent to report symptoms of his service-connected disabilities and how such conditions affect his employability. Additionally, he is credible in his reports during clinical evaluations of symptoms and their effect on his activities. Layno v. Brown, 6 Vet. App. 465 (1994). But, as a lay person he is not competent to identify a specific level of disability according to the appropriate diagnostic code or to assess whether the symptoms preclude employment. Such competent evidence concerning the nature and extent of the Veteran’s service-connected disabilities, and in particular his ability to work, have been provided by the VA medical professional who examined him. As such, the Board finds the Veteran’s statements, including the lay statement from the Veteran’s fellow colleague, not competent medical evidence for this purpose. Thus, the lay assertions standing alone have little probative value and the Board assigns more weight to the medical opinions provided by VA examiners. Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Based on the foregoing, the Board finds that the preponderance of the evidence is against a finding that the Veteran is rendered unemployable due to his service-connected disabilities. Even though the Veteran met the applicable percentage standards, the Board nevertheless finds that the criteria under 38 C.F.R. § 4.16(a) have not been met and TDIU is not warranted. Accordingly, the claim must be denied. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 4. Entitlement to service connection for left knee disability with osteoarthritis is denied. The Veteran contends that his current left knee disability is etiologically related to service or service-connected right knee disability. While the record shows a current diagnosis of left knee osteoarthritis, the Board finds that there is no medical evidence of record to support a finding that the claimed left knee disability had onset in service or is otherwise etiologically related to service or service-connected right knee disability. The record shows a VA contract examination of August 2018 where the examiner found that the current left knee disability was less likely incurred in or caused by an in-service injury, event or illness. The examiner noted that the Veteran’s medical records show right knee was affected after being struck by car in 1982 during service. There is no notation of left knee injury. In compliance with the September 2019 Board remand, an additional VA medical opinion was obtained in January 2020, which the Board finds constitutes the most probative medical evidence of record. After thorough review of the electronic claims file, the VA examiner indicated that the current left knee disability diagnosed as left knee osteoarthritis is less likely incurred in or caused by an in-service injury or event. The rationale provided was that a “diagnosis of left knee osteoarthritis was made 27 years after separation from service.” The examiner found no objective evidence of chronic left knee pain with consistent chronological nexus dating back to military service. The examiner added that VA treatment records note left knee surgery in 2003 and that the veteran reported being hit by a truck in 1994. See VA medical opinion dated November 2015. Additionally, the January 2020 examiner rendered an opinion finding that it was less likely that the Veteran’s left knee disability was proximately caused by or aggravated, beyond the natural progression of the disease, by his service-connected right knee disability. In support of the conclusion, the examiner stated there is no evidence of treatment notes to support aggravation of left knee condition by right knee condition. In fact, the examiner indicated that there is no medical documentation available for review for left knee after 1992. According to medical history, the Veteran had trauma separate from active service and is now over the age of 60 which are additional factors that contribute to left knee osteoarthritis. Id. The Board finds probative the VA medical opinions and objective evidence of record which establishes onset of left knee joint osteoarthritis approximately 27 years after discharge from service. Essentially, there is no evidence of record even suggesting an etiological connection between the current left knee disability and service or to service-connected right knee disability. Additionally, the Board recognizes the Veteran’s contentions that his claimed left knee disability is related to service or a service-connected disability.  Although the Veteran is certainly capable of describing the history in this case as well as his symptoms in and after service, as a layperson, without any demonstrated, specialized knowledge concerning the etiology of these disabilities, his allegations are not competent evidence of a medical nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). For this purpose, the Board finds the Veteran’s lay statements do not constitute competent medical evidence.  Therefore, his assertions, standing alone, have little probative value and the Board assigns more weight to the August 2018 and January 2020 medical opinions of the VA examiners. After weighing all the evidence, the Board observes that the objective medical evidence of record stands uncontradicted by any other evidence found in the record and is probative in determining whether the Veteran has substantiated his claim for service connection. Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran’s claim for service connection for left knee disability. The benefit-of-the-doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. A., 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.