Citation Nr: 20052965 Decision Date: 08/10/20 Archive Date: 08/10/20 DOCKET NO. 12-06 789 DATE: August 10, 2020 ORDER 1. Entitlement to service connection for left knee disability, to include degenerative joint disease (DJD) and as secondary to service-connected right thigh myositis ossificans is denied. 2. Entitlement to service connection for right knee disability, to include DJD and as secondary to service-connected right thigh myositis ossificans is denied. 3. Entitlement to a total disability rating based on individual unemployability due to the service-connected disabilities (TDIU), is denied and referral for extraschedular TDIU is not warranted. FINDINGS OF FACT 1. The evidence does not show that the Veteran’s left knee disability is related to military service, was aggravated or caused by the service-connected right thigh myositis ossificans, or that arthritis was manifested to a compensable degree within a year of service discharge. 2. The evidence does not show that the Veteran’s right knee disability is related to military service, was aggravated or caused by the service-connected right thigh myositis ossificans, or that arthritis was manifested to a compensable degree within a year of service discharge. 3. The Veteran’s service-connected disabilities did not preclude all substantially gainful employment for which his education and occupational experience would otherwise have qualified him. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for left knee disability, to include DJD and as secondary to service-connected right thigh myositis ossificans, have not been met. 38 U.S.C. §§ 1131, 1116, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3.310. 2. The criteria for entitlement to service connection for right knee disability, to include DJD and as secondary to service-connected right thigh myositis ossificans, have not been met. 38 U.S.C. §§ 1131, 1116, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3.310. 3. The criteria for a TDIU were not met on a schedular basis and referral for extraschedular consideration was not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the Marine Corps from April 1980 to June 1983. In March 2019, the Board remanded the issues of entitlement to service connection for a right and left knee disability, to include DJD and as secondary to service-connected right thigh myositis ossificans as well as entitlement to a TDIU. The appeal has been returned to the Board for further appellate review. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection requires competent evidence of (1) a current disability; (2) the incurrence or aggravation of a disease or injury during service; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disability which is aggravated by a service-connected disability. In order to prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). For certain chronic diseases, including arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For those listed chronic diseases, a showing of continuity of symptoms affords an alternative route to service connection when the requirements for application of the presumption are not met. 38 C.F.R. § 3.30 (b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). In relevant part, 38 U.S.C. § 1154 (a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability or death benefits. 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). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 at 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. It may also 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. 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 symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Left Knee Disability Regarding the Veteran’s claim for service connection for a left knee disability, he has a current diagnosis of left knee joint osteoarthritis in March 2011, left knee degenerative arthritis confirmed in May 2015, left knee degenerative joint disease in October 2016, and total left knee arthroplasty, noted in April 2019. As such, the current disability prong for service connection has been met. As noted above, service connection is presumed for chronic disabilities that manifest within a specific period. 38 U.S.C. § 1101 (3); 38 C.F.R. § 3.309(a). Arthritis, including a left knee disability with degenerative arthritis, is listed among the chronic disabilities to which this presumption attaches. 38 C.F.R. § 3.309(a). In the instant case, there is no evidence of the Veteran’s chronic disability manifested in service. A review of the Veteran’s service treatment records shows that there is no documentation of arthritis of the left knee in service and characteristic manifestations of the disease processes were not identified. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Specifically, the Veteran’s separation examination does not report any knee problems, and there is no accompanying medical history questionnaire on which the Veteran might have reported a continuing knee disability. Further, the Veteran’s service treatment records do not reflect injuries to the Veteran’s knees and the Veteran’s complaints and treatments in service are only for a muscle strain and muscle pain. Notably, the Veteran’s service treatment records do not reflect a diagnosis of arthritis. Additionally, arthritis affecting the Veteran’s left knee disability did not manifest to a compensable degree within one year of discharge. 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). The Board notes that the Veteran had a VA examination in August 1983, and he reported no knee pain and the examiner did not diagnosis the Veteran with any knee disability. Additionally, the first post-service medical reference to knees is a May 1999 private treatment record in which the Veteran complained of pain in knees. Because the evidence does not show that the Veteran had a chronic disability in service or that the Veteran’s chronic disability first manifested to a compensable degree within one year of discharge, service connection on the basis of a presumed chronic disability is not applicable. 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). If there is insufficient evidence, as in this instance, showing that the currently-diagnosed chronic disease was chronic during service or within a presumptive period, a veteran may still be entitled to presumptive service connection if continuity of symptomatology is demonstrated. § 3.303(b). The Board acknowledges that at an August 2009 SSA examination, the Veteran stated that, “he has been having this problem [knee pain] for about 5-6 years. Moreover, the Veteran has no medical treatment records showing that he reported knee pain since his discharge from service until a May 1999 private treatment record in which the Veteran complained of knee pain. Therefore, service connection based on continuity of symptomatology is not applicable. 38 C.F.R. §§ 3.303(b). In addition, service connection cannot be established on a direct basis for the left knee. Significantly, service treatment records are silent for complaints of, or treatment for left knee pain. The Veteran reported no in-service injury or event to his left knee in service. The Board does note that service treatment records report in February 1983, the Veteran was assessed with a muscle strain of the right thigh after he pulled a muscle in the right thigh while playing basketball. In follow-up service medical records, the Veteran continued to complain of muscle “pain in the medial [right] thigh muscle” and did not complain of any knee pain. In April 1983, the Veteran was diagnosed with a right thigh muscle spasm (noting service treatment records show no in-service diagnosis or treatment for knee pain). The Veteran indicated in the May 1983 on the Report of Medical History at separation that he had “right thigh problems.” There was no mention of right or left knee issues and there was a denial of current or past “trick or locked knee.” At the May 1983 separation examination, the examiner referenced “myositis R femur” and “myositis ossificans R thigh” but no reference to knees. As such, service treatment records are silent for complaints of, or treatment for right and left knee pain. Post-service medical indicate that a private medical statement from October 2016 states that the Veteran injured his knee while serving in the military and that the physician diagnosed the Veteran with degenerative joint disease. The Board is free to assess medical evidence and is not obligated to accept a physician’s opinion. Wilson v. Derwinski, 2 Vet. App. 614 (1992). In this case, the Board declines to accept the October 2016 private medical opinion. While the Board acknowledges that the opinion reflects, in pertinent part, that the Veteran injured left knee while in active service, the Board notes that this opinion is problematic because it does not provide an adequate rationale in support of the physician’s opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 123-25 (2007) (an adequate medical opinion addresses the appropriate theories of entitlement and provides a supporting rationale for any medical opinion); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008 (noting a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). The October 2016 private medical opinion does not indicate as to which knee, right or left, the physician is referring nor is there any statement as to any date of the injury to coincide with any military service. Also, there is no discussion of any medical evidence reviewed to include in-service medical records as well as any post-service medical records and no rationale was provided for the opinion. Thus, the October 2016 medical opinion does not form a sufficient foundation upon which to base a grant of entitlement to service connection, and the Board affords this medical opinion less probative weight. Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2009). Significantly, the Board notes that throughout the current appeal period, there is no medical evidence that illustrates a positive medical nexus between the Veteran’s left knee and active service. Further, the Board notes that VA examinations in November 2015 and May 2019 both reported that the Veteran’s left knee disability was not related to his active service. The probative value attributed to a VA or private medical opinion issued with regard to a service connection claim depends on factors such as thoroughness, degree of detail, and whether there was a complete review of the veteran’s claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the November 2015 and May 2019 VA examiner’s opinions were both adequately supported by a comprehensive review of the Veteran’s medical records, including his service treatment records and post-service VA and private treatment records. Specifically, the November 2015 VA examiner stated in their rationale that the Veteran had no history of knee pain during active service and that the first diagnosis of a left knee disability came at least 25 years after active service. Similarly, the May 2019 VA examiner stated in their rationale that the Veteran had no history of trauma to the left knee in active service. Additionally, the VA examiner’s both took into account for the Veteran’s competent and credible lay statements, regarding his current knee pain. The Board finds that the foregoing medical opinions adequate and highly probative of a positive medical nexus between the Veteran’s current knee disabilities and his active duty because both VA examiners reviewed the Veteran’s relevant medical history and offered clear opinions regarding the relationship between the Veteran’s left knee disability and his active service. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, the Board has considered the Veteran’s lay statements throughout the appeal period that his left knee is related to service. The Board notes that lay persons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, as to the etiology of a left knee disability, the issue of causation of such a medical condition is a medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Thus, although the Board has carefully considered the lay contentions of record suggesting that the Veteran’s left knee disability to active service, the Board has not uncovered any credible medical evidence which supports such a connection, and the Veteran lacks the medical expertise to competently determine the etiology of his left knee disability. Significantly, there is no competent evidence of record associating the Veteran’s left knee disability with his active duty. In sum, after carefully reviewing the record, the Board finds the preponderance of the evidence is against the Veteran’s claim for service connection for a left knee disability, on a direct basis. Here, there are no findings, or diagnoses, of any left knee pain or disability in service treatment records, including at separation. Additionally, there is no in service injury documented to the Veteran’s left knee. There is also no medical evidence suggesting that a left knee disability was diagnosed within the one-year presumptive period after service. 38 C.F.R. §§ 3.307, 3.309. Unfortunately, post-service medical records do not indicate an adequate positive medical nexus between the Veteran’s left knee disability and his active service. Accordingly, the Board finds that the most probative evidence demonstrates that the Veteran’s current left knee disability did not develop in service. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). Thus, service connection for a left knee disability, on a direct basis, is no warranted. Alternatively, the Veteran asserts that service connection for left knee disability is warranted because he believes that it resulted from his service-connected right thigh myositis ossificans. As the Veteran has a current left knee disability and is service connected for right thigh myositis ossificans, the salient question is whether there is medical nexus evidence establishing a connection between the service-connected disability and the current disability. The Board finds that a preponderance of the evidence is against a finding of a medical nexus establishing a connection between the current left knee disability and the service connected for right thigh myositis ossificans. The Board notes that an April 2019 VA DBQ examination was conducted and the examiner stated that the Veteran’s left knee was at least as likely as not proximately due to or the result of the Veteran’s service connected condition. The examiner’s rationale was that the pain in the right thigh muscle could cause the Veteran to shift weight, this putting more stress on the knees. The Board notes that a May 2019 VA addendum medical opinion was provided to clarify the April 2019 medical opinion for whether the Veteran’s left knee was at least as likely as not proximately due to or the result of the Veteran’s service-connected right thigh myositis ossificans. The addendum was provided because the April 2019 opinion, that the Veteran’s left knee was at least as likely as not proximately due to or the result of the Veteran’s service-connected condition, was deemed inadequate. The Board agrees. The April 2019 VA examiner’s rationale that the pain in the right thigh muscle could cause the Veteran to shift weight, this putting more stress on the knees, is not adequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. at 295 (noting a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). The examiner’s use of the word could, is not a clear medical conclusion and thus, the April 2019 VA medical opinion is given less probative weight as it does not form a sufficient foundation to justify a positive medical nexus between the Veteran’s currently diagnosed left knee disability and his service-connected right thigh myositis ossificans. As stated above, the Veteran had a VA addendum medical opinion for his knee disabilities in May 2019. The VA examiner opined that the Veteran’s left knee disability is less likely than not proximately due to, or the result of, his service-connected right thigh myositis ossificans. Further, the VA examiner opined that the Veteran’s left knee disability was not aggravated beyond its natural progression by the service-connected right thigh myositis ossificans. The examiner reasoned that the Veteran had no history of trauma to the left knee in the military and that a cause and effect relationship between knee arthritis and thigh myositis ossificans has not been established to date by a preponderance of the medical evidence. The Board notes that the Veteran was afforded an earlier November 2015 VA examination which reported that the Veteran’s left knee disability is less likely than not proximately due to, or the result of, his service-connected right thigh myositis ossificans. The examiner stated that a review of medical literature found no studies linking myositis ossificans to an ipsilateral or contralateral joint (knee) diagnosis. Additionally, the examiner noted that the left knee osteoarthritis, is related to the aging process which occurred post his service tenure and unrelated to his service-connected myositis ossificans. The Board notes that the November 2015 VA aggravation opinion is inadequate because the aggravation opinion simply separates out the symptoms and restates their cause without addressing aggravation. Thus, the November 2015 VA examination and opinion does not form a sufficient foundation upon which to base a denial of entitlement to service connection, and the Board affords this medical opinion less probative weight. Nieves- Rodriguez v. Peake, 22 Vet. App. at 304. Significantly, the Board notes that throughout the current appeal period, there is no medical evidence that illustrates an adequate positive medical nexus between the Veteran’s current left knee disability and his service connected for right thigh myositis ossificans. The Board acknowledges that both the April 2019 VA examination, which opined a positive medical nexus, and the November 2015 VA examination, which opined a negative medical nexus, were both inadequate and given less probative weight. Additionally, the Board finds the May 2019 VA medical examiner’s opinion that the Veteran’s current left knee disability was both not proximately due and not aggravated by his service-connected right thigh myositis ossificans, adequate and highly probative. After careful review of the evidence, the Board finds that the competent evidence of record also fails to reflect an association between the Veteran’s current left knee disability and his service connected for right thigh myositis ossificans. Moreover, there is no competent evidence that the Veteran’s current left knee disability was caused or aggravated by his service-connected right thigh myositis ossificans. Notwithstanding statements offered by the Veteran in which he attributes his left knee disability to his service, to include service-connected his right thigh myositis ossificans, the Board finds that he is not competent to provide an opinion as to the etiology of his left knee disability. Jandreau, 492 F.3d at 1376-77. Accordingly, the preponderance of evidence is against a finding of service connection for left knee disability, to include DJD and as secondary to service-connected right thigh myositis ossificans. Therefore, the appeal must be denied as to this issue. There is no reasonable doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Right Knee Disability Regarding the Veteran’s claim for service connection for a right knee disability, he has a current diagnosis of right knee joint osteoarthritis in March 2011, right knee degenerative arthritis confirmed in May 2015 and in April 2019. As such, the current disability prong for service connection has been met. As noted above, there is no evidence of the Veteran’s chronic disability in service. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a). A review of the Veteran’s service treatment records shows that there is no documentation of arthritis of the right knee in service and characteristic manifestations of the disease processes were not identified. See Walker v. Shinseki, 708 F.3d at 1338. Additionally, arthritis affecting the Veteran’s right knee disability did not manifest to a compensable degree within one year of discharge. 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). The Board notes that the Veteran had a VA examination in August 1983, and he reported no knee pain and the first post-service medical reference to knees is a May 1999 private treatment record. Lastly, as noted above, if there is insufficient evidence, as in this instance, showing that the currently diagnosed chronic disease was chronic during service or within a presumptive period, a veteran may still be entitled to presumptive service connection if continuity of symptomatology is demonstrated. § 3.303(b). Here, the first medical evidence indicating the Veteran having knee pain came over 15 years after the Veteran’s honorable discharge from active service in 1999. Further, as noted above, at an August 2009 SSA examination, the Veteran stated that, “he has been having this problem [knee pain] for about 5-6 years.” Therefore, service connection based on continuity of symptomatology is not applicable. 38 C.F.R. §§ 3.303(b). In addition, service connection cannot be established on a direct basis for the right knee. Significantly, service treatment records are silent for complaints of, or treatment for right knee pain. The Veteran reported no in-service injury or event to his right knee in service. Additionally, the May 1983 separation examination showed normal knees and there is nothing in the record noting that the Veteran made any statements he was having knee pain in service, just right thigh pain from a diagnosed right thigh muscle spasm. As stated above, for the Veteran’s left knee disability, post-service medical records indicate that a medical statement from October 2016 states that the Veteran injured his knee while serving in the military. As the Board noted, this private medical opinion is inadequate, and the Board affords this medical opinion less probative weight. See Nieves- Rodriguez v. Peake, 22 Vet. App. at 304. Significantly, the Board notes that throughout the current appeal period, there is no medical evidence that illustrates a positive medical nexus between the Veteran’s right knee and active service. Further, the Board acknowledges that VA examinations in November 2015 and May 2019 both report that the Veteran’s right knee disability is not related to his active service. As noted above, the Board finds both examinations and medical opinions adequate and highly probative of a negative medical nexus between the Veteran’s current right knee disability and his active duty. See Nieves- Rodriguez v. Peake, 22 Vet. App. at 295. Specifically, the November 2015 VA examiner stated in their rationale that the Veteran had no history of knee pain during active service and that the first diagnosis of a right knee disability came at least 25 years after active service. Further, the May 2019 VA examiner stated that the Veteran had no history of trauma to the right knee in active service. Additionally, the Board has considered the Veteran’s lay statements throughout the appeal period that his right knee is related to service. The Board acknowledges that lay persons are competent to provide opinions on some medical issues. However, as to the etiology of a left knee disability, the issue of causation of such a medical condition is a medical determination outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F. 3d at 1376-77. Thus, although the Board has carefully considered the lay contentions of record suggesting that the Veteran’s right knee disability to active service, the Board has not uncovered any credible medical evidence which supports such a connection, and the Veteran lacks the medical expertise to competently determine the etiology of his left knee disability. Significantly, there is no competent evidence of record associating the Veteran’s right knee disability with his active duty. In sum, after carefully reviewing the record, the Board finds the preponderance of the evidence is against the Veteran’s claim for service connection for a right knee disability, on a direct basis. Here, there are no findings, or diagnoses, of any right knee pain or disability in service treatment records, including at separation. Additionally, there is no in service injury documented to the Veteran’s right knee. Accordingly, the Board finds that the most probative evidence demonstrates that the Veteran’s current right knee disability did not develop in service. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). Thus, service connection for a right knee disability, on a direct basis, is no warranted. Alternatively, the Veteran asserts that service connection for right knee disability is warranted because he believes that it resulted from his service-connected right thigh myositis ossificans. However, the Board finds that a preponderance of the evidence is against a finding of a medical nexus establishing a connection between the current right knee disability and the service-connected right thigh myositis ossificans. As stated above, the Veteran had a VA examination for his knee disabilities in May 2019. The VA examiner opined that the Veteran’s right knee disability is less likely than not proximately due to, or the result of, his service-connected right thigh myositis ossificans. Further, the VA examiner opined that the Veteran’s right knee disability was not aggravated beyond its natural progression by the service-connected right thigh myositis ossificans (noting that the examiner also opined that the right knee disability was less likely than not related to active service). The examiner stated in their rationale that the Veteran had no history of trauma to the right knee in the military and that a cause and effect relationship between knee arthritis and thigh myositis ossificans has not been established to date by a preponderance of the medical evidence. The Board also notes that the Veteran was afforded an earlier November 2015 VA examination which reported that the Veteran’s right knee disability is less likely than not proximately due to, or the result of, his service-connected right thigh myositis ossificans. The examiner stated that they reviewed medical literature and found no studies linking myositis ossificans to an ipsilateral or contralateral joint (knee) diagnosis. Additionally, the examiner noted that the right knee osteoarthritis, is related to the aging process which occurred in the Veteran’s post service tenure and is unrelated to his service-connected myositis ossificans. The Board notes that the November 2015 VA aggravation opinion is inadequate because aggravation opinion simply separates out the symptoms and restates their cause without addressing aggravation. Thus, the November 2015 VA examination and opinion does not form a sufficient foundation upon which to base a denial of entitlement to service connection, and the Board affords this medical opinion less probative weight. Nieves- Rodriguez v. Peake, 22 Vet. App. at 304. Significantly, the Board notes that throughout the current appeal period, there is no medical evidence that illustrates an adequate positive medical nexus between the Veteran’s current right knee disability and his service connected for right thigh myositis ossificans. The Board acknowledges that the November 2015 VA examination, which opined a negative medical nexus, was inadequate and given less probative weight. Additionally, the Board finds the May 2019 VA medical examiner’s opinions that the Veteran’s current right knee disability was both not proximately due and not aggravated by his service-connected right thigh myositis ossificans, adequate and highly probative. After careful review of the evidence, the Board finds that the competent evidence of record also fails to reflect an association between the Veteran’s current right knee disability and his service connected for right thigh myositis ossificans. Moreover, there is no competent evidence that the Veteran’s current right knee disability was caused or aggravated by his service-connected right thigh myositis ossificans. Accordingly, the preponderance of evidence is against a finding of service connection for right knee disability, to include DJD and as secondary to service-connected right thigh myositis ossificans. Therefore, the appeal must be denied as to this issue. There is no reasonable doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. TDIU 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. 38 C.F.R. § 4.16(a). If, however, the veteran does not meet these required percentage standards set forth in 38 C.F.R. § 4.16 (a), he still may receive a TDIU on an extraschedular basis if it is determined that he is unable to secure or follow a substantially gainful occupation by reason of his service-connected disabilities. 38 C.F.R. § 4.16(b); Fanning v. Brown, 4 Vet. App. 225 (1993). Thus, there must be a determination as to whether there are circumstances in this case, apart from any nonservice-connected conditions and advancing age, which would justify a total rating based on unemployability. Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). Being unable to maintain substantially gainful employment is not the same as being 100 percent disabled. The term ‘substantially gainful occupation’ does not “set a clear numerical standard for determining a TDIU” but does indicate an amount less than total. Roberson v. Principi, 251 F.3d 1378 (Fed Cir. 2001). Assignment of a TDIU evaluation requires that the record reflect some factor that “takes the claimant’s case outside the norm” of any other veteran rated at the same level. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Id. The applicable regulations place responsibility for the ultimate TDIU determination on VA, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). TDIU is to be awarded based on the judgment of the rating agency. Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). By this decision, the Veteran’s combined schedular rating is 40 percent. Further, the Veteran does not have at least one disability rated 40 percent or more. As such, he does not meet the schedular rating criteria for a TDIU. 38 C.F.R. §§ 4.16(a), 4.25, 4.26. Where, as here, the Veteran does not meet the schedular criteria for a TDIU, an extraschedular TDIU may be warranted where the evidence shows that the veteran is precluded, by reason of his service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a veteran’s level of education, special training, and previous work experience, but not to his age or the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Unlike the regular disability rating schedule which is based on the average work-related impairment caused by a disability, “entitlement to a TDIU is based on an individual’s particular circumstances.” Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). The ultimate question of whether a Veteran is capable of substantial gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to: (1) the veteran’s history, education, skill, and training; (2) whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran’s limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and (3) whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran’s limitations, if any, concerning memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The Veteran’s work history indicates that he last worked in April 2009 as a tire manufacturer. Previously from February 2005 to October 2007, he had worked in light fixture manufacturing and from 1994 to December 2004, he worked in car bumper manufacturing. In the Veteran’s December 2011 TDIU Application (VA Form 21-8940), the Veteran asserted that his knee conditions, specifically, bilateral degenerative joint disease of the knees, prevent him from securing or following any substantially gainful employment. As noted above in this decision and throughout the current appeal period, service connection for both a left and right knee disability have not been granted. The central inquiry for entitlement to 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). Consideration may be given to his or her level of education, special training, and previous work experience, but advancing age and the impairment caused by nonservice-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2015); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran has asserted that he is unable to work, however, the evidence of record does not support that it is a result of his service-connected disabilities. Moreover, the Veteran has not even contended that his service-connected conditions alone are sufficient to cause his unemployability. Throughout the appeal period, the Veteran has cited his nonservice-connected bilateral degenerative joint disease of the knees as the primary reason for his current inability to obtain and maintain substantial and gainful employment. On the Veteran’s application for compensation and pension in December 2011, the Veteran indicated that his knee conditions were the disabilities that had prevented him from working. However, as noted above, the Board notes that the Veteran is not service connected for any knee condition. The Board notes that private, as well as VA treatment reports, show that the Veteran suffers from severe degenerative joint disease of both knees. Additionally, SSA records stated that the Veteran has tried repeatedly to work but he will not be able to remain gainfully employed. See May 2010 private medical opinion (noting that an April 2010 SA Physical Functional Capacity Assessment found that Veteran could occasionally lift/carry 20 pounds and frequently lift/carry 10 pounds. Also found he could stand/walk for “about 6 hours in an 8-hour workday” and sit for “about 6 hours in an 8-hour workday). The Board notes that this opinion only references the Veteran’s non service-connected knee conditions. Further, SSA records also show that there were no findings that the Veteran’s service-connected disabilities of pseudofolliculitis barbae, right thigh myositis ossificans, and hemorrhoids had any impact on his occupational impairment. Additionally, throughout the current appeal period, various VA examinations have indicated that the Veteran’s service-connected disabilities do not preclude the Veteran from engaging in all forms of substantially gainful employment consistent with his experience. Specifically, a January 2016 VA Social Work and Industrial Survey considered whether the Veteran’s service-connected right thigh myositis ossificans, pseudofolliculitis barbae, tinnitus, and hemorrhoids precluded the Veteran from working. The examiner’s opinion and rationale were that, “when assessing all of the service-connected disabilities in combination, I would opine that the Veteran would be able to sustain substantially gainful activity at a sedentary level. He would be capable of standing and walking up to 2 hours and lifting and carrying 20 pounds frequently.” Additionally, the examiner stated that “when assessing all of the service-connected disabilities in combination and despite [the Veteran’s] pain issues, I would opine that the Veteran would not be expected to have any significant difficulty articulating and interacting effectively within a social setting.” As mentioned above, however, the central inquiry for entitlement to TDIU is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad, 5 Vet. App. at 529 (1993) (emphasis added). Here, the Veteran has contended that his knee conditions cause unemployability. However, the Board has acknowledged that the Veteran is not service connected for his left and right knee disabilities. Additionally, even if the Veteran was contending his other service-connected disabilities precluded him from working, the Board finds that the Veteran has not identified or submitted any competent evidence demonstrating that his service-connected disabilities precluded him from securing and maintaining substantially gainful employment and entitled him to a TDIU. As such, the claims file does not show that the Veteran is unable to obtain or maintain substantially gainful employment. The Board does not believe that the Veteran’s service-connected disabilities prevent him from obtaining or maintaining substantially gainful employment. While the Veteran may have other disabling conditions that are not service-connected, a TDIU is not warranted unless the service-connected conditions by themselves cause impairment that is sufficient to produce unemployability. As none of the evidence of record supports that he is unable to work due to his service-connected disabilities alone, the Board finds that referral for consideration of TDIU on an extraschedular basis is not warranted, and the appeal in this matter must be denied. See 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. CAROLE R. KAMMEL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Dourmashkin, Law Clerk 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.