Citation Nr: 20043731 Decision Date: 06/29/20 Archive Date: 06/29/20 DOCKET NO. 16-43 671 DATE: June 29, 2020 ORDER A rating in excess of 10 percent for a right ankle disability prior to August 26, 2016 is denied. From August 26, 2016, entitlement to a 20 percent, but no higher, rating for a right ankle disability is granted, subject to the regulations governing the payment of monetary awards. Service connection for a low back condition, to include as secondary to a service-connected disability, is denied. Service connection for a bilateral leg condition, to include as secondary to a service-connected disability, is denied. Service connection for an acquired psychiatric disorder, to include as secondary to a service-connected disability, is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. Prior to August 26, 2016, the Veteran’s right ankle disability was shown to manifest in moderate limitation of motion, even when considering additional factors of pain and functional loss. 2. From August 26, 2016, the Veteran’s right ankle disability has been manifested by marked limitation of motion, when considering additional factors of pain, swelling, weakened movement, instability of station, disturbance of locomotion, and interference with standing. 3. The evidence weighs against a finding that the Veteran’s low back condition was incurred in service or is otherwise related to an in-service event, injury, or disease; that the condition was caused or aggravated beyond its natural progression by a service-connected disability; or, that the Veteran’s disability manifested to a compensable degree within a year of service or was noted during service with continuity of the same symptomatology since separation. 4. The evidence weighs against a finding that the Veteran’s bilateral leg condition was caused or aggravated beyond its natural progression by a service-connected disability. 5. The evidence weighs against a finding that the Veteran’s acquired psychiatric disorder is caused or aggravated beyond its natural progression by a service-connected disability. 6. The Veteran’s service-connected disability does not preclude him from securing or following substantially gainful employment consistent with his education and industrial background. CONCLUSIONS OF LAW 1. Prior to August 26, 2016, the criteria for a rating in excess of 10 percent for a right ankle disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5271. 2. From August 26, 2016, the criteria for a rating of 20 percent, but no higher, for a right ankle disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5271. 3. The criteria for service connection for a low back condition, to include as secondary to a service-connected disability, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.310(a), 3.310(b). 4. The criteria for service connection for a bilateral leg condition, to include as secondary to a service-connected disability, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310(a), 3.310(b). 5. The criteria for service connection for an acquired psychiatric disorder, to include as secondary to a service-connected disability, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310(a), 3.310(b), 4.125(a). 6. The criteria for entitlement to a TDIU are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1980 to July 1986. This matter is on appeal from January 2015 (of which the Veteran was notified in May 2015) and May 2017 decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The case was previously before the Board in March 2019 when it was remanded for further development.   Increased Rating In general, disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity caused by a given disability, and separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 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). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. For example, lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing observable symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In both initial and increased rating claims, the Board must consider staged ratings for the entire period on appeal. A staged rating is appropriate when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings under the applicable diagnostic code. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). The potential for staged ratings accounts for the possible dynamic nature of a disability while the claim works its way through the adjudication process. Id. The Board has therefore considered the claim on appeal with the potential for a staged rating in mind. The Board notes that it has reviewed all of the evidence in the record, with 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 need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as to the claim being decided. 1. Right Ankle Prior to August 26, 2016 The Veteran contends that he is entitled to an increased rating for his service-connected right ankle disability. The Veteran’s right ankle disability is currently assigned a 10 percent rating under hyphenated Diagnostic Code 5024-5271. Hyphenated Diagnostic Codes are used when a rating under one diagnostic code requires the use of an additional one to identify the basis for the rating assigned; the additional diagnostic code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5024 is used to evaluate tenosynovitis and states that it will be rated on limitation of motion of the affected parts, as arthritis, degenerative. Degenerative arthritis is evaluated under Diagnostic Code 5003 and provides that arthritis will be evaluated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. Diagnostic Code 5271 assigns disability ratings based on limitation of motion of the ankle. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limitation of motion. A 20 percent rating is warranted for marked limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5271. Normal range of motion of the ankle includes plantar flexion from 0 degrees to 45 degrees and dorsiflexion (extension) from 0 degrees to 20 degrees. 38 C.F.R. § 4.71a, Plate II. When the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In Petitti v. McDonald, 27 Vet. App. 415 (2015), the United States Court of Appeals for Veterans Claims (Court) rejected VA’s argument that § 4.59 requires painful motion, such that the mere presence of joint pain is not sufficient. Id. at 428-29. The Court held that under § 4.59, “the trigger for a minimum disability rating is an actually painful, unstable, or malaligned joint,” explaining that § 4.59 speaks to both painful motion of joints and actually painful joints. Id. at 425. Moreover, the Court held that § 4.59 does not require “objective” evidence but can be satisfied with lay and other non-medical evidence. Id. at 429. Higher ratings are assignable under Diagnostic Code 5270 for ankylosis of the ankle. Under Diagnostic Code 5270, ankylosis of the ankle in plantar flexion less than 30 degrees warrants a 20 percent rating. If ankylosed in plantar flexion between 30 degrees and 40 degrees, or in dorsiflexion between 0 degrees and 10 degrees, a 30 percent rating is warranted. If ankylosed in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees, or with abduction, adduction, inversion or eversion deformity, a 40 percent rating is warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5270. When evaluating musculoskeletal disabilities, VA may consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). In this case, the Veteran was provided with a VA examination in December 2010. The Veteran reported right ankle pain described as severe intermittent pain with moderate intermittent stiffness and weakness which occurs 4 times daily with a duration of 1 hour. The Veteran presented with a normal gait and denied the use of canes, crutches, walkers, braces, or wheelchairs. He reported difficulty standing more than 3 hours, walking for more than 1 hour, walking up and down steps, and climbing due to right ankle pain. Range of motion testing revealed dorsiflexion 0 to 20 degrees, plantar flexion 0 to 45 degrees, inversion 0 to 30 degrees, and eversion 0 to 40 degrees. There was evidence of mild or minimal pain of the right ankle with dorsiflexion 10 to 20 degrees, plantar flexion 35 to 45 degrees, inversion 20 to 30 degrees, and eversion 30 to 40 degrees. With repetitive use, the range of motion did not elicit additional pain, fatigue, weakness, or lack of endurance. The Veteran denied any flare-ups of the right ankle condition. There was evidence of mild tenderness noted along the anterior and lateral aspects of the right ankle, but there was no swelling, no heat, no redness, and no drainage. There was minimal weakness and minimal stiffness but no deformity, no instability, no locking, no effusion, no dislocation, and no subluxation. The Veteran was provided with an additional VA examination in January 2013. The Veteran reported continued pain in the right ankle. Range of motion testing showed plantar flexion from 0 to 40 degrees with pain at 40 degrees and dorsiflexion from 0 to 20 degrees with pain at 20 degrees. With 3 repetitive ranges of motions, the right ankle measurements were unchanged and not further diminished by pain, fatigue, weakness, or lack of endurance. He did not have additional limitation in range of motion with repetitive testing. Joint stability testing showed no laxity when compared with the opposite side and there was full strength of the ankle in plantar flexion and dorsiflexion. The Veteran did not have ankylosis of the right ankle, subtalar, or the tarsal joint. He did not use an assistive device for locomotion. There was a functional impact on his ability to do any type of work that requires walking for more than one hour, standing for more than 3 hours, continuously walking up and down steps, or doing heavy physical carrying or moving or lifting. He reported that he worked in construction but had to stop working because he was unable to walk for more than one hour, stand for more than 3 hours, walk up or down steps, or carry heavy objects. He reported that he worked in security for the last year and was able to do that job because he had rest periods in between walking and standing and was not required to lift heavy objects or walk up and down steps. The Board recognizes the Veteran’s complaints of pain and functional loss as a result of his right ankle disability, notably his difficulty with prolonged standing and walking. When considering the reports of functional loss as shown by the VA examinations and the Veteran’s reports of pain, the Veteran’s right ankle disability prior to August 26, 2016 was not shown to be manifested by more than moderate limitation of motion. The VA examinations during this period reflected that dorsiflexion was full and that plantar flexion was at most limited to 40 degrees. There was no additional loss of motion during repetitive use testing and no indication that the functional loss resulted in limitation of motion that would more nearly approximate marked limitation. Thus, even when considering the reported pain and associated functional loss, the Veteran’s disability picture did not more nearly approximate marked limitation of motion. As such, a rating in excess of 10 percent prior to August 26, 2016 is not warranted. Increased evaluations under other potentially applicable Diagnostic Codes have also been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The evidence of record does not show that the Veteran has tibia and fibula impairment, ankylosis, a heel bone fracture, or has had an astragalectomy. Therefore, a rating under Diagnostic Codes 5262, 5270, 5272, 5273, or 5274 is not warranted. 38 C.F.R. §§ 4.7, 4.71a. In sum, the criteria for a rating in excess of 10 percent for right ankle disability have not been met prior to August 26, 2016. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55.   2. Right Ankle from August 26, 2016 In argument received by VA on August 26, 2016, the Veteran’s attorney reported that during a recent conversation with the Veteran he had told his attorney that he now needed to use a cane due to his right ankle and that by the end of the day his right ankle was swollen, tender, and painful when he removed his shoe. He also reported that his ankle becomes weaker as time goes by. In a VA Form 21-4138, Statement in Support of Claim, received in December 2016, the Veteran reported swelling of the ankle “to the point that [he cannot] tie [his] shoes.” He reported constant aching and difficulty running, standing, or walking for any long length of time. He reported using a brace and cane for support. He reported incidents involving falls due to stepping on uneven surfaces or trying to avoid obstacles. A January 2018 private treatment record reflects that the Veteran reported experiencing right ankle pain and instability. The provider noted swelling and tenderness of the lateral malleolus and anterior talofibular ligament. She also noted limited dorsiflexion and limited plantar flexion but did not provide specific range of motion findings. The anterior drawer and inversion stress tests were negative. In a November 2018, VA Form 21-4138, the Veteran reported that he continued to experience problems with ankle swelling from standing or walking longer distances. He reported being unable to run and reported difficulty maintaining work due to constant swelling and aching. He reported using a cane for support when he expects to walk or stand for a long time. In January 2019 written correspondence, the Veteran’s representative stated that the Veteran’s November 2018 statement reflected that he has instability in the ankle and that the Veteran had reported having multiple falls due to instability and stepping on uneven surfaces when walking. The Veteran appeared for an additional VA examination in November 2019. The Veteran reported flare-ups of the ankle with prolonged walking and standing. Range of motion testing revealed dorsiflexion from 0 to 15 degrees and plantar flexion from 0 to 40 degrees. No pain was noted on examination. There was no evidence of pain with weight bearing, no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, and no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional loss of function or range of motion after three repetitions. The examiner noted that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. The examiner noted that the examination was not conducted during a flare-up but noted that pain caused additional limitation in functional ability with a flare-up, with an estimated dorsiflexion from 0 to 10 degrees and plantar flexion from 0 to 35 degrees. Muscle strength testing was normal for plantar flexion and dorsiflexion. The Veteran had no muscle atrophy and no ankylosis. The examiner noted that no ankle instability or dislocation was suspected. She noted that the Veteran constantly used a cane for locomotion for back and ankle disabilities. She noted that imaging studies of the ankle had been performed and that degenerative or traumatic arthritis was not documented. The examiner noted a clinical history of degenerative joint disease and an impression of calcified loose body seen at the medial malleolus in keeping with the prior fracture with no acute fracture or dislocation identified and mild bony spurring seen in the plantar calcaneus. In examining the evidence, the Board concludes that from August 26, 2016, the Veteran is entitled to a higher 20 percent rating based on findings that more nearly approximate marked limitation of motion of the right ankle. Specifically, from that date, it is factually ascertainable that the Veteran utilized a cane and a brace for ankle instability, reported having fallen on several occasions, and reported weakness in the ankle. The VA examinations also reflect a greater limitation of motion during flare ups. Thus, when considering the additional factors of pain, swelling, weakened movement, instability of station, disturbance of locomotion, and interference with standing, the Board finds that the Veteran’s right ankle disability more nearly approximates the criteria for a higher 20 percent rating for marked limitation of motion from August 26, 2016. Increased evaluations under other potentially applicable Diagnostic Codes have also been considered but are inapplicable for the reasons discussed above. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In sum, a 20 percent, but no higher, rating is warranted from August 26, 2016. 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 military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish service connection, the Veteran must show: (1) a current disability, (2) a disease, injury, or event in service, and (3) a causal link (nexus) between the claimed disability and the disease, injury, or event in service and the present disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that it was either caused or aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a), (b); Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including arthritis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. An alternative method of establishing incurrence or aggravation and a nexus to service is through a demonstration of continuity of symptomatology. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was noted during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. The theory of continuity of symptomatology can be used only in cases involving those diseases explicitly recognized as chronic under 38 C.F.R. § 3.309(a), such as arthritis. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Low Back Condition The Veteran contends that he is entitled to service connection for a low back condition, to include as secondary to a service-connected disability. In this case, December 2019 private treatment records reflect that the Veteran has a diagnosis of lumbar discopathy as revealed in an MRI. The first element of Shedden is therefore satisfied. Further, the record reflects that the Veteran experienced back pain in service. May 1981 service treatment records note sharp pain in the back and stooping. May 1984 service records note low back pain, swelling and discoloration, left lateral muscle pain, muscle tightness with tenderness to palpation, and possible muscle strain. Thus, the second element of Shedden is satisfied, as well. However, upon review of the record, the Board finds that the evidence preponderates against a finding that the Veteran’s current disability was incurred in service or is otherwise related to an in-service event, injury, or disease. The Veteran was provided with a VA examination in June 2011 in which the examiner opined that it is less likely than not that the Veteran’s current low back disability is related to the low back strain that occurred on active duty. The examiner noted that there is an absence of documentation indicating a continuing problem of low back pain on active duty and absence of documentation of a continuing low back condition since separation from active duty approximately 25 years ago. Generally, the absence of contemporaneous medical records would not, in and of itself, necessarily weigh against the claim. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, as will be explained below, the Board finds that a preponderance of the evidence is against a finding that the Veteran has experienced continuous back pain since service. As such, the Board finds that the June 2011 VA opinion adequately addresses the etiology of the condition, and the Board assigns a moderate to high degree of probative value to this opinion given the examiner’s reasonable rationale and consideration of the record as a whole. In January 2017, the Veteran submitted a letter from a primary care provider who stated that the Veteran reported that he “has had chronic low back pain since he was injured [in service] … [and] since then he has had chronic back pain and spasms for 3 years and [has needed] medication management due to pain.” However, January 2019 private treatment records note that the Veteran had a prior injury in the 1980’s in service to his back but noted a full recovery. The clinician noted that the Veteran was working as a Security Guard when he was injured and was shoveling snow when he slipped and fell backwards striking his lumbosacral spine and tailbone. Notably, the Veteran reported that “he was pain free prior to this accident.” The Board places greater weight on these recent statements, as statements made for the purpose of medical diagnosis or treatment are considered to be exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment. White v. Illinois, 502 U.S. 346, 356 (1992). This discrepancy, in addition to the absence of contemporaneous evidence of continuous pain since separation, compels the Board to find that the January 2017 letter does not provide a reliable account of the history of the back condition. As such, the Board finds that the evidence preponderates against a finding that the Veteran has experienced continuous chronic low back pain since his injury in service. This matter was remanded in March 2019 in order to obtain an opinion addressing the Veteran’s alternative theory of secondary service connection. In November 2019, the Veteran was provided with an additional VA examination in which the examiner opined that the Veteran’s back condition is a separate, unrelated condition to his service-connected right ankle sprain with tendonitis. The examiner stated that the pathologies of each condition are unique to the individual condition. The examiner also stated that there is no conclusive evidence that the Veteran’s multilevel lumbar spondylosis has been aggravated beyond its natural progression by the right ankle condition. This opinion reflects consideration of the pathology of the Veteran’s conditions and reflects consideration of the record as a whole. As such, the Board assigns a moderate to high degree of probative value to this opinion. Accordingly, the Board finds that the evidence preponderates against a finding that the Veteran’s current low back condition was incurred in service or is otherwise related to an in-service event, injury, or disease. Further, the evidence preponderates against a finding that the Veteran’s low back condition was caused or aggravated beyond its natural progression by a service-connected disability, to include the Veteran’s right ankle disability. The record also preponderates against a finding that the Veteran’s disability manifested to a compensable degree within a year of service or was noted during service with continuity of the same symptomatology since separation. The Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is the against the claim, that doctrine is not applicable, and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 4. Bilateral Leg Condition The Veteran contends that he is entitled to service connection for a bilateral leg condition, to include as secondary to his low back condition. In this case, the record does not reflect that the Veteran has been diagnosed with a bilateral leg condition. However, the Veteran provided credible and competent reports of bilateral leg spasms in a January 2012 VA Form 21-526, Veteran’s Application for Compensation and/or Pension. Additionally, the January 2017 letter from a primary care provider discusses that the Veteran’s legs give out (i.e., cause him to stumble or fall) due to numbness. Thus, the Board finds that the evidence establishes the presence of signs or symptoms of a disability which result in functional impairment of earning capacity, and the first element of Shedden is satisfied. This matter was previously remanded, as it is inextricably intertwined with the Veteran’s remanded claim for entitlement to service connection for a low back condition. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). However, as discussed above, the criteria for establishing service connection for a low back condition are not met. As such, the Board finds that there is no evidence which indicates that the Veteran’s bilateral leg condition is caused or aggravated beyond its natural progression by a service-connected disability. 38 C.F.R. § 3.310(a), (b); Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc). Regarding any potential theory relating to a direct nexus, the Board acknowledges that April 1985 service treatment records note that the Veteran had a slight limp from a right foot injury after playing basketball. Further, June 1986 service treatment records note that the Veteran reported cramps in his legs. In a September 1986 VA Form 21-4138, Statement in Support of Claim, the Veteran explained that he sustained an injury playing basketball in service and was placed in a cast on the right leg and had difficulty walking. However, there is no indication, and the Veteran has not alleged, that the right foot injury and leg cramping which was noted decades ago is related to his current symptoms of bilateral leg spasms and numbness. As indicated above, the Veteran is already service connected for a right ankle disability. The Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is the against the claim, that doctrine is not applicable, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 5. Acquired Psychiatric Disorder The Veteran contends that he is entitled to service connection for an acquired psychiatric disorder, to include as secondary to a service-connected disability. In this case, an April 2017 VA examination report reflects that the Veteran has a current diagnosis of adjustment disorder with depressed mood. This diagnosis was provided in conformance with the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V), which is required for establishing a current disability for a mental disorder. 38 C.F.R. § 4.125(a). Thus, the first element of Shedden is satisfied. However, upon review of the record, the Board finds that the evidence preponderates against a finding that the Veteran’s acquired psychiatric disorder is caused or aggravated beyond its natural progression by a service-connected disability. The April 2017 examination report reflects that the examiner opined that the Veteran’s adjustment disorder with depressed mood is at least as likely as not secondary to the claimed back and leg spasm condition, and less likely than not secondary to the service-connected ankle disorder. She stated that the timeline of symptom onset supports this nexus, along with the focus of the Veteran’s depressive ideation on the symptoms and impairment associated with the claimed back and leg spasm condition. Notably, during the examination, the “Veteran was clear in attributing his current level of distress to his back and leg spasm condition, and not to the [service-connected] ankle condition.” As this opinion reflects thorough consideration of the Veteran’s pertinent medical history and is supported by the record, the Board assigns a high degree of probative value to this opinion. In July 2019, Dr. J.D., a private medical provider, submitted a letter in which he provided a diagnosis of “MDD (recurrent/severe); secondary to service-connected ankle injury w/ anxious features.” The clinician noted that the Veteran reported that his service-connected ankle disability “has plagued him ever since leaving the service” and that he “also asserts having some severe anxiety due to his service-connected disability.” However, the clinician also stated that, “taking all available data into account and with the information listed above, [the Veteran] suffers the primary symptoms clusters necessary to warrant a diagnosis of MDD with anxious features, secondary to his service-connected knee injuries.” Additionally, the report indicates that the Veteran reported that his depression was directly related to his service-connected hearing condition, however, the Veteran is not service connected for a hearing disability. This opinion reflects consideration of the Veteran’s medical history and was provided by a mental health professional with specialized expertise and training; however, the Board finds that this opinion has little weight of probative value given the lack of clarity in the statements regarding to precisely which disability the Veteran’s acquired psychiatric disorder is secondarily related. The Board acknowledges the medical articles submitted by the Veteran and his representative which discuss associations between chronic pain and mental disorders. However, these articles are too general in nature and do not specifically reference the facts of the Veteran’s case. See Sacks v. West, 11 Vet. App. 314, 316 (1998) (finding that medical treatise evidence on its own is generally too abstract to prove the nexus element of a service connection claim); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (holding that medical evidence that is speculative, general, or inconclusive cannot be used to support a claim). Thus, the Board does not assign any weight of probative value to these medical articles. As such, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s acquired psychiatric disorder is caused or aggravated beyond its natural progression by a service-connected disability. Additionally, the record contains no evidence which otherwise indicates that the Veteran’s acquired psychiatric disorder was incurred in or caused by an in-service event, injury, or disease. The Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable, and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 6. TDIU The Veteran contends that he is entitled to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The Veteran is service connected for a right ankle disability, rated as 10 percent disabling prior to August 26, 2016, and as 20 percent disabling thereafter, as a result of the above decision. As such, the percentage criteria for a TDIU under 38 C.F.R. § 4.16(a) are not satisfied, as there is not a single service-connected disability rated as 60 percent or more or two or more disabilities with at least one disability rated at 40 percent or more and sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Although the percentage requirements of section 4.16(a) are not met, if the evidence establishes that the Veteran was unable to secure and follow a substantially gainful occupation by reason of service-connected disability, the case will be referred for extraschedular consideration. 38 C.F.R. § 4.16(b). The central inquiry in a claim for TDIU 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 United States Court of Appeals for Veterans Claims (Court) has held that the term unable to secure and follow a substantially gainful occupation in 38 C.F.R. § 4.16 has two components. First, there is an economic component which essentially contemplates an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Second, there is a non-economic component dealing with the individual veteran's ability to follow and secure employment. For the second component, attention must be given to: (a) the veteran's history, education, skill and training, (b) the veteran's physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy or very heavy) required by the occupation at issue, with relevant factors such as lifting, bending, sitting, standing, walking, climbing, grasping, typing, reaching, auditory and visual, and (c) whether the Veteran has the mental ability to perform the type of activities required by the occupation at issue, with relevant factors such as memory, concentration, and ability to adapt to change, handle work place stress, get along with coworkers and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 72-73 (2019). On December 2010 VA examination, the Veteran reported having difficulty standing more than 3 hours, walking for more than 1 hour, walking up and down steps, and climbing due to right ankle pain. On January 2013 VA examination, the examiner noted that the Veteran’s right ankle disability had a functional impact on the Veteran’s ability to do any type of work that required walking for more than one hour, standing for more than 3 hours, or continuously walking up and down steps or doing heavy physical carrying or moving or lifting. The examiner noted that the Veteran worked in construction after service but had to stop that type of work due to the above restrictions. The examiner noted that the Veteran had been working in security for the last year and that he was able to do that job because he had rest periods in between walking, standing, and was not required to lift heavy objects or walk up and down steps. The examiner indicated that there was no functional impact in regard to the Veteran’s ability to do any type of sedentary work. In an October 2015 statement, the Veteran reported that he had attempted to seek employment that allowed him to sit and hopefully stand. He reported having successfully obtained a driving job and a security job, but that both were short lived because of constant calling off due to pain and complaining about sitting or standing for long durations, since such put a lot of strain and pressure on his lower back. On April 2017 VA psychiatric examination, the Veteran reported that he had a limited ability to perform physical chores, such as cutting the grass, raking, planting flowers, or climbing a ladder due mainly to his back condition. On November 2019 VA examination, the examiner found that the Veteran’s right ankle disability did not impact his ability to perform any type of occupational task. As such, the Board finds that the preponderance of the evidence of record weighs against a finding that the Veteran’s service-connected disability is of sufficient severity to render him unable to secure or follow a substantially gainful occupation. Although the evidence reflects that the Veteran’s right ankle disability has a functional impact on employment, the evidence is not supportive that his right ankle disability alone has resulted in him being unable to secure or follow substantially gainful employment. The record reflects the Veteran has other nonservice-connected conditions, namely his lumbar spine disability, that also affect his employment capability. In examining the Veteran’s history, education, skill and training, and his physical ability to perform job-related activities, the Board finds that his service-connected right ankle disability alone would not preclude him from performing the activities of jobs for which he would be qualified, including his former employment in security or as a driver. Therefore, referral for extraschedular consideration is not warranted, and the claim is denied. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. H. White, 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.