Citation Nr: 21003066 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 16-11 730 DATE: January 19, 2021 ORDER Entitlement to a disability rating in excess of 30 percent for a left knee disability, status post knee replacement surgery, is denied. Entitlement to a disability rating in excess of 10 percent for a right knee disability is denied. Entitlement to a separate initial rating of 20 percent, but no higher, for a right knee meniscal condition is granted. Entitlement to service connection for a right ankle disorder, to include as secondary to the service-connected lumbar spine disability is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. The Veteran’s left knee disability is manifested by decreased motion and pain, with flexion limited to, at most, 95 degrees, but there is no evidence of ankylosis at any point during the appeal, which results in an overall disability picture of intermediate degrees of residual weakness, pain, or limitation of motion. 2. The Veteran’s right knee disability is manifested by decreased motion and pain, with flexion limited to, at most, 95 degrees, but there is no evidence of ankylosis at any point during the appeal. 3. The Veteran’s right knee meniscus disability is manifested by frequent episodes of “locking” and pain of the joint. 4. The preponderance of the evidence is against a finding that the Veteran has a right ankle disorder that is due to or aggravated by his military service. 5. The Veteran’s service-connected disabilities prevent him from obtaining and retaining substantially gainful employment consistent with his educational background and work experience CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for the left knee disability status post total knee replacement have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 2. The criteria for a rating in excess of 10 percent for the right knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5260. 3. The criteria for a separate initial rating of 20 percent, but no higher, for a right knee meniscus disability have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5258. 4. The criteria for service connection for a right ankle disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 5. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.3, 4.7, 4.15, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February1961 to February 1964. This appeal to the Board of Veterans’ Appeals (Board) is from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. In February 2018, the Veteran testified at a Videoconference hearing before the undersigned Veterans Law Judge. A copy of the transcript is associated with the claims file. In April 2018, the Board remanded this matter to the RO for additional development and consideration. All requested actions have been completed and the appeal is once again before the Board for adjudication. Increased Ratings Disability ratings are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C. § 1155. Percentage ratings are determined by comparing the manifestations of a particular disability with the requirements contained in VA’s Schedule for Rating Disabilities. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from a disease or injury and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 3.102, 4.3. 1. Left and Right Knee Disabilities Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a , Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a noncompensable evaluation where flexion of the leg is limited to 60 degrees. For a 10 percent evaluation, flexion must be limited to 45 degrees. For a 20 percent evaluation is warranted where flexion is limited to 30 degrees. A 30 percent evaluation may be assigned where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent evaluation where extension of the leg is limited to five degrees. A 10 percent evaluation requires extension limited to 10 degrees. A 20 percent evaluation is warranted where extension is limited to 15 degrees. A 30 percent evaluation may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent evaluation, extension must be limited to 30 degrees. Where extension is limited to 45 degrees, a 50 percent evaluation may be assigned. Under Diagnostic Code 5259, a 10 percent rating can be assigned for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a 20 percent evaluation can be assigned for cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint. Id. Evaluations for a knee impairment can also be assigned due to ankylosis or genu recurvatum. 38 C.F.R. § 4.71a , Diagnostic Codes 5256, 5263 (2018). Diagnostic Code 5257 governs other impairments of the knee. 38 C.F.R. § 4.71a. A 10 percent rating is appropriate for slight recurrent subluxation or lateral instability of the knee. Id. A 20 percent rating is assigned for moderate recurrent subluxation or lateral instability of the knee. Id. A 30 percent rating is assigned for severe recurrent subluxation or lateral instability of the knee. Id. Finally, Diagnostic Code 5055 provides for ratings following total knee replacement surgery. Diagnostic Code 5055 provides that a 100 percent evaluation is assigned for one year following the implantation of the prosthesis. A 60 percent evaluation is assigned for a prosthetic replacement of the knee joint with chronic residuals consisting of severe painful motion or weakness in the affected extremity. The minimum rating for a prosthetic replacement of the knee joint is 30 percent. Intermediate ratings between 30 and 60 percent may also be assigned by analogy if evidence shows that such a rating is warranted under Diagnostic Codes 5256, 5261, or 5262. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Normal range of knee motion is 140 degrees of flexion and 0 degrees of extension. 38 C.F.R. § 4.71, Plate II. For the sake of brevity, the Board will address all evidence associated with the right and left knee disabilities below and then undertake a separate analysis pertaining to each individual disability. Procedural and Factual Background The Veteran is seeking higher ratings for his service-connected right and left knee disabilities. On March 4, 2013, the Veteran submitted evidence regarding the current severity of his right and left knee disabilities. Thereafter, on March 22, 2013, a Report of General Information clarified the Veteran’s intent regarding the submission of the evidence, and determined that he was requesting an increase for his service-connected right and left knee disabilities. See March 2013 Report of General Information. Therefore, the relevant temporal focus is from March 4, 2012, one year prior to the date of his accepted “Intent to File.” 38 C.F.R. § 3.400. The Veteran was initially examined by VA in June 2013 in connection with his claim for increased ratings. The VA examiner noted diagnoses of right knee degenerative joint disease and left knee total knee arthroscopy (TKA). The Veteran denied flare-ups. He reported that the left knee is stiff in the morning, and he occasionally has thigh cramps. The Veteran also stated that the left knee scar has been numb since his surgery in December 2003. Regarding the right knee, the Veteran reported pain when weight bearing and after prolong immobility. The Veteran reported the right knee clicks, but it does not swell, lock, buckle, or grind. The Veteran does not require the use of assistive devices. The Veteran reported that he is unable to walk more than 1.5 blocks; lift more than 50 pounds; stand still for more than 15 minutes; or, run, jump, kneel, or squat. The Veteran stated he retired from the police force in 1991 due to his knee disabilities, and the examiner noted the knee disabilities do impact the Veteran’s ability to work. Upon physical examination of the right knee, range of motion testing revealed flexion to 110 degrees, with no evidence of pain; and, extension to 0 degrees with no evidence of pain. Mild crepitus was noted with movement. The Veteran was able to perform repetitive use testing with no additional loss in range of motion or functional impairment. There was no evidence of tenderness or pain on palpation. Muscle strength testing and stability testing were normal for the right knee. There was no evidence of recurrent subluxation/dislocation, or any other conditions affecting the right knee, to include meniscal conditions. Upon physical examination of the left knee, range of motion testing revealed flexion to 95 degrees, with no evidence of pain; and, extension to 0 degrees with no evidence of pain. The Veteran was able to perform repetitive use testing with no additional loss in range of motion or functional impairment. There was no evidence of tenderness or pain on palpation. Muscle strength testing was normal, but stability testing revealed a value of +1 for anterior instability in the left knee. There was no evidence of recurrent subluxation/ dislocation, or any other conditions affecting the left knee. The examiner noted a prior meniscectomy of the left knee in 1982, but indicated there were no residual signs or symptoms as result of that surgery. Further, the Veteran underwent a total knee joint replacement in December 2003. The examiner noted the presence of two scars on the left knee, which were described as flat, non-tender, normal color, numb, fixed, without induration or tissue loss, and without functional impact. One scar is noted to be located at the mid-line anterior, measuring 21 centimeters (cm) by 0.2 cm, and the other is medial measuring 12 cm by 0.8 cm. The Veteran was next examined by VA in October 2013. At that time, the VA examiner noted diagnoses of right knee degenerative joint disease and left knee total knee replacement (TKR). The Veteran denied flare-ups. He reported that the left knee is stiff in the morning, and he occasionally has thigh cramps. The Veteran also stated that the left knee scar has been numb since his surgery in December 2003. Regarding the right knee, the Veteran reported pain when weight bearing and after prolong immobility. The Veteran reported the right knee clicks, but does not swell, lock, buckle, or grind. The Veteran requires the regular use of an assistive device, a brace, for the right knee only. He also receives a cortisone shot in the right knee. Regarding any impact on the Veteran’s ability to work, the examiner stated that the Veteran is unable to do any physical labor due to knee pain. Further, walking and standing is limited, but he is able to do sedentary type of work with no restrictions and with light duty. Upon physical examination of the right knee, range of motion testing revealed flexion to 110 degrees, with no evidence of pain; and, extension to 0 degrees with no evidence of pain. The Veteran was able to perform repetitive use testing with no additional loss in range of motion. However, the examiner noted functional impairment resulting in pain, less movement, swelling, deformity, and interference with sitting, standing, and weight-bearing. There was no evidence of tenderness or pain on palpation. Muscle strength testing and stability testing were normal for the right knee. There was no evidence of recurrent subluxation/dislocation, or any other conditions affecting the right knee. X-ray findings noted subtle chondrocalcinosis of the lateral meniscus, and minimal narrowing of the medical meniscus. Upon physical examination of the left knee, range of motion testing revealed flexion to 95 degrees, with no evidence of pain; and, extension to 0 degrees with no evidence of pain. The Veteran was able to perform repetitive use testing with no additional loss in range of motion. However, the examiner noted functional impairment resulting in pain, less movement, swelling, deformity, and interference with sitting, standing, and weight-bearing. There was no evidence of tenderness or pain on palpation. Muscle strength testing and stability testing were normal for the left knee. There was no evidence of recurrent subluxation/dislocation. The examiner again noted a prior meniscectomy of the left knee, but indicated there were no residual signs or symptoms as result of that surgery. Further, the Veteran underwent a total knee joint replacement in December 2003, resulting in intermediate degrees of residual weakness, pain or limitation of motion. The examiner noted the presence of two scars on the left knee, but indicated they were not unstable or painful, or covered an area greater than 39 squared centimeters. The Veteran was most recently examined by VA in August 2019. At that time, the Veteran reported some stiffness in the left knee. He also noted intermittent pain in the right knee with swelling, occurring every other day. He also stated that he experiences flare-ups with walking, which results in limitations on prolonged walking. Regarding any impact on the Veteran’s ability to work, the examiner noted the Veteran was a police officer until 1991, but bilateral knee pain precludes Veteran from running. Right knee pain interferes with prolonged walking, and negotiating stairs. Upon physical examination of the right knee, range of motion testing revealed flexion to 95 degrees, and extension to 0 degrees, with evidence of pain on motion. There was no evidence of pain on weight-bearing, but there was evidence of tenderness or pain on palpation, and crepitus. The Veteran was able to perform repetitive use testing with no additional loss in range of motion or functional impairment. The examiner noted the Veteran was not being examined immediately after repetitive use or during a flare-up, but the examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Further, pain, weakness, fatigability or incoordination does not significantly limit functional ability with repeated use over a period of time or during a flare-up. The examiner explained that there is no conceptual or empirical basis for making such a determination without directly observing the knee over a period of time or during a flare-up. Further, the examiner stated there is a lack of supporting objective documentation in the claims file and, therefore, it is not possible to estimate loss of range of motion, without resorting to mere speculation again, due to the lack of conceptual or empirical evidence. Moreover, there is no persistent evidence of record, considered to be valid or reproducible for ratings purposes, that indicates a loss of function during these conditions. Muscle strength testing and stability testing were normal for the right knee. There was no evidence of recurrent subluxation/ dislocation, muscle atrophy, or ankylosis. Upon physical examination of the left knee, range of motion testing revealed flexion to 110 degrees and, extension to 5 degrees, with pain on motion. There was no evidence of tenderness or pain on palpation, pain on weight-bearing, or crepitus. The Veteran was able to perform repetitive use testing with no additional loss in range of motion or functional impairment. The examiner noted the Veteran was not being examined immediately after repetitive use or during a flare-up, but the examination is neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. Further, pain, weakness, fatigability or incoordination does not significantly limit functional ability with repeated use over a period of time or during a flare-up. The examiner explained that there is no conceptual or empirical basis for making such a determination without directly observing the knee over a period of time or during a flare-up. Further, the examiner stated there is a lack of supporting objective documentation in the claims file and, therefore, it is not possible to estimate loss of range of motion, without resorting to mere speculation again, due to the lack of conceptual or empirical evidence. Moreover, there is no persistent evidence of record, considered to be valid or reproducible for ratings purposes, that indicates a loss of function during these conditions. Muscle strength testing and stability testing were normal for the left knee. There was no evidence of recurrent subluxation/ dislocation, muscle atrophy, or ankylosis. The examiner again noted a prior meniscectomy of the left knee, but indicated there were no residual signs or symptoms as result of that surgery. Further, the Veteran underwent a total knee joint replacement in December 2003, resulting in intermediate degrees of residual weakness, pain or limitation of motion. The examiner noted the presence of two scars on the left knee, but indicated they were not unstable or painful, or covered an area greater than 39 squared centimeters. The examiner noted one scar was located midline and described as a vertical incision left knee, measuring 21 cm by 0.5 cm. The other scar, a vertical medial scar, measured 7 cm by 0.8 cm. Also, of record are VA and private treatment records dated throughout the appeals period, from 2012 to the present. A February 2013 private treatment record noted a tear of the body and posterior horns of the medial meniscus, and continuing right knee pain. See February 2013 Private Treatment Record. Aside from these findings, the VA and private treatment records do not contain any additional objective evidence of record, to include range of motion readings that are materially different from the information included in the VA examinations of record discussed above. The Board also notes the Veteran submitted a statement from his wife dated in April 2014 attesting to the severity of the Veteran’s left and right knee disabilities. Specifically, his wife states that due to the pain in his knees, he cannot sleep, cannot drive, and cannot work. She describes physical limitations in the Veteran’s ability to lift objects and walk for long distances. Further, the Veteran’s wife noted that the pain in the right and left knees has intensified over the past few years. During his February 2018 Board hearing, the Veteran again testified to increasing pain and functional limitations on account of his bilateral knee disabilities. Legal Analysis Left Knee Disability By way of procedural history, the Board notes that the Veteran underwent a total knee replacement surgery in December 2003. Thereafter, from December 11, 2003 to February 1, 2005, the Veteran was in receipt of a 100 percent rating, pursuant to Diagnostic Code 5055. Effective from February 1, 2005, the Veteran was assigned a 30 percent rating, which is the minimum rating following a total knee replacement surgery. These ratings are consistent with the holding in Tedesco v. Wilkie, 31 Vet. App. 260 (2019). On March 4, 2013, as noted above, the Veteran filed a claim for an increased rating for his left knee disability. Based on the evidence as noted above, the Board finds that the Veteran is not entitled to a rating in excess of the 30 percent currently assigned for residuals of his total left knee replacement at any point during the period on appeal, from March 4, 2012. This is based on the provisions of Diagnostic Code 5055, which provides for a minimum rating of 30 percent. The evidence shows limitation of left knee flexion limited to, at most, 95 degrees, which corresponds to a noncompensable rating under Diagnostic Code 5260. See June 2013 VA Knee and Lower Leg Examination Disability Benefits Questionnaire (DBQ), June 2013 Medical Opinion, and October 2013 VA Knee and Lower Leg Conditions DBQ. Further, there is no indication of extension limited to 30 degrees, which would warrant a higher 40 percent rating under Diagnostic Code 5261. His extension was limited to, at most, 5 degrees extension, as noted in the August 2019 VA examination report. See 38 C.F.R. §§ 4.10, 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). As the Veteran’s limitation of flexion and extension are both noncompensable, the only appropriate compensable rating based on limitation of motion is the 30 percent rating provided for in Diagnostic Code 5055. 38 C.F.R. § 4.71a , Diagnostic Code 5055. Additionally, there is no indication of ankylosis of the left knee. Therefore, a rating in excess of the 30 percent rating already assigned is not for application pursuant to Diagnostic Code 5256. There are no other pertinent diagnostic codes that would afford the Veteran a rating in excess of this 30 percent rating. A 60 percent rating based on severe painful motion or severe weakness under Diagnostic Code 5055 is not warranted. The findings of the June 2013, October 2013, and August 2019 VA examiners, as discussed above, would not constitute severe painful motion as the codes pertaining to limitation of motion provide for higher ratings that the Veteran’s measured ranges do not nearly approximate. In fact, his limitation of flexion, found to be 95 degrees at its worst, does not warrant a compensable rating and thus could not be considered severe, even considering his complaints of constant pain and stiffness. Moreover, the October 2013 and August 2019 VA examiners specifically found that the Veteran’s total knee replacement resulted in an intermediate degree of residual weakness, pain, or limitation of motion and they did not find evidence of severe painful motion. The Board has considered whether a separate and/or higher evaluation is warranted under an alternate diagnostic code. However, as noted above, the preponderance of the evidence weighs against a finding of ankylosis; dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the knee joint; symptomatic removal of semilunar cartilage; or, malunion or nonunion of the tibia and fibula. Therefore, a separate or increased rating for left knee symptomatology pursuant to Diagnostic Codes 5256, 5258, 5259, or 5262, is not warranted. The Board notes the June 2013 VA examiner found +1 for the left knee anterior instability. However, this is the only indication of any instability in the left knee. Therefore, the Board considers this finding of anterior instability, as opposed to lateral instability as denoted in Diagnostic Code 5257, an outlier especially where examinations prior to and after do not find any instability, actually finding it normal. See June 2013 VA Knee and Lower Leg Examination Disability Benefits Questionnaire (DBQ); but see also October 2013 VA Knee and Lower Leg Conditions DBQ and August 2019 VA Knee and Lower Leg Conditions DBQ. Given such, a separate rating is not warranted pursuant to Diagnostic Code 5257. The Board has also considered the Veteran’s lay statements in support of his claim for a higher rating, and those of his wife. As noted above, the Veteran’s wife submitted a statement in April 2014 attesting to the severity of the Veteran’s left knee disability. Specifically, she stated that due to the pain in his knees, he cannot sleep, cannot drive, and cannot work. She describes physical limitations in the Veteran’s ability to lift objects and walk for long distances. See again April 2014 Statement in Support of Claim. The Veteran also testified to pain and limitation of motion due to pain during his February 2018 Board hearing, and he is certainly competent to report knee pain. Further, there is no doubt that he experiences this as he does have some limited motion as shown on the examinations conducted during the appeals period. The Court has held that “limitation of motion” and “painful motion” are distinct concepts, although limitation of motion is a factor that may be considered to determine whether painful motion is present. Tedesco v. Wilkie, 31 Vet. App. 360, 365-66 (2019). However, here, even considering the Veteran and his wife’s reports of pain and limitation of motion as a result of pain, the medical evidence of record does not result in a disability picture manifested by severe pain and/ or weakness. In fact, even considering his statements as to the severity of his left knee disability during his February 2018 Board hearing and in the April 2014 statement from his wife, the Veteran has never been shown to have any weakness as a result of his left knee disability. See again June 2013, October 2013, and August 2019 VA Knee and Lower Leg Conditions DBQs. Moreover, while the Board acknowledges the Veteran’s statements as to the chronic nature of his pain, the evidence does not show that the severity of the pain equates to “severe painful motion,” but shows that there are limitations in the activities of daily living as a result of pain. Finally, even when considering the Veteran’s reports of pain and any potential impact on his ability to move, his range of motion has never been limited to more than 95 degrees flexion and 5 degrees extension in the left knee. Additionally, whether the Veteran's left knee disability resulted in a level of functional loss greater than that already contemplated by the assigned ratings for any part of the appeal period has also been considered. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. Following his surgery and for the entire period on appeal, the Veteran noted functional impairment of the left knee is characterized by pain and stiffness. However, the rating schedule is intended to allow for compensation for painful motion of a joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Thus, the evidence does not reflect functional loss that is not already contemplated by the assigned rating of 30 percent. A rating in excess of 30 percent is not warranted for the left knee on the basis of functional loss under the aforementioned regulations. Regarding the holding in Correia, the Board notes the only evidence of pain on weight-bearing was noted in the October 2013 VA Knee and Lower Legs Conditions DBQ, at which time the VA examiner noted the existence of pain on weight-bearing. To this extent, the Board notes that the pain noted on examination is specifically encompassed in the criteria for Diagnostic Code 5055, such that consideration is given to pain in assigning the current 30 percent rating. There is no indication from the objective evidence of record to support a rating in excess of 30 percent due to pain on weight-bearing. Regarding the holding in Sharp, the only reported flare-up was in the August 2019 VA Knee and Lower Legs Conditions DBQ, which was found to be characterized as limitations of prolonged walking. The August 2019 VA examiner also specifically found there was no persistent evidence of record, considered to be valid or reproducible for ratings purposes, that indicates a loss of function during a flare-up. Considering all the evidence of record, the examiner ultimately noted pain, weakness, fatigability or incoordination does not significantly limit functional ability during a flare-up, which would indicate a higher rating is warranted on this basis. In sum, the Board finds that the symptoms noted by the Veteran during his VA examinations are contemplated under the relevant rating criteria and under the Deluca criteria, including §§ 4.40 and 4.45, which compensate for limitation of motion, and symptoms such as pain, weakness, and instability producing functional limitations. C.F.R. 4.40, 4.45, 4.59; Mitchell, 25 Vet. App. at 44 ; Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Moreover, even considering his subjective complaints of pain and other symptoms described in DeLuca, the evidence of record shows that motion of the Veteran’s left knee has been limited to no less than 95 degrees, which is properly rated as 30 percent disabling under Diagnostic Code 5055. In reaching the above conclusions, the Board has not overlooked the Veteran’s statements with regard to the severity of his left knee disability, to include his prior Board hearing testimony and the April 2014 statement from his wife. In this regard, the Veteran and his wife are competent to report on factual matters of which they had firsthand knowledge, e.g., experiencing chronic pain in his left knee. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran has provided lay evidence through written statements, his Board hearing, and during his examinations throughout the course of his appeal with respect to the symptomatology associated with his left knee. He is competent to provide such statements, and the Board finds that the Veteran’s statements and those of lay witnesses to be credible. The Veteran’s reported symptomatology has been noted in the several examinations conducted during the appeals period and noted above, and the Board has considered the Veteran’s reports with respect to pain in evaluating his assigned ratings. However, the Board finds that the Veteran is not competent to assign a disability rating as this requires medical expertise and understanding of the musculoskeletal system. Therefore, the medical findings provided by the Veteran’s VA examination reports have been accorded greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (“[t]he probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches... the credibility and weight to be attached to these opinions [are] within the province of the adjudicator.”). Accordingly, as the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Right Knee Disability The Veteran is seeking a higher disability rating for his service-connected right knee disability, which is rated as 10 percent disabling under Diagnostic Code 5010-5260 for arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260. The hyphenated diagnostic code in this instance indicates that traumatic arthritis under Diagnostic Code 5010 is the service-connected disorder, and limitation of flexion of the leg is the residual condition under DC 5260. See 38 C.F.R. § 4.27. Based on the evidence as discussed above, the Board finds that a rating in excess of 10 percent for the right knee is not warranted at any point during the appeals period. In this respect, pursuant to Diagnostic Code 5260, flexion limited to 30 degrees is 20 percent and flexion limited to 15 degrees is 30 percent. Here, the evidence shows the Veteran’s flexion has been limited to, at most, 95 degrees. See October 2013 VA examination. The VA and private treatment records do not include any range of motion findings that would support the assignation of the higher 20 or 30 percent ratings. The Board has also considered whether a separate rating based on limitation of extension pursuant to Diagnostic Code 5261. However, the record shows the Veteran’s extension has been 0 degrees without pain throughout the pendency of the appeal. Therefore, a separate 10 percent rating is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Board has considered whether a separate or higher evaluation is warranted under an alternate diagnostic code. In this respect, the Board notes the findings of the February 2013 private treatment record show a tear of the body and posterior horns of the medial meniscus. See February 2013 Private Treatment Record. The June 2013 and October 2013 VA examination reports also note the Veteran’s reports of clicking and pain in the right knee. Therefore, the Board finds a separate rating of 20 percent is warranted under Diagnostic Code 5258. Under Diagnostic Code 5259, removal of semilunar cartilage that is symptomatic will be assigned a 10 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259. There is no express indication of whether the Veteran has undergone a removal of his meniscus such that Diagnostic Code 5259 would apply. As to whether separate ratings are available under any other diagnostic codes, as noted above, the preponderance of the evidence weighs against a finding of ankylosis, instability, or malunion or nonunion of the tibia and fibula. Therefore, a separate or increased rating for right knee symptomatology pursuant to Diagnostic Codes 5256, 5257, or 5262 is not warranted. Additionally, whether the Veteran’s right knee disability resulted in a level of functional loss greater than that already contemplated by the assigned rating at any point during the appeal period has also been considered. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. A claimant may be entitled to a higher disability evaluation for a musculoskeletal disability than that supported by mechanical application of the rating schedule where there is evidence that his or her disability causes additional functional loss—i.e., "the inability . . . to perform the normal working movements of the body with normal excursion, strength, speed, coordination[,] and endurance"—including as due to pain. 38 C.F.R. § 4.40 (2020); see Lyles v. Shulkin, 29 Vet. App. 107, 117 (2017). A higher disability evaluation may also be awarded where there is a reduction of a joint's normal excursion of movement in different planes, including changes in the joint's range of movement, strength, fatigability, or coordination. 38 C.F.R. § 4.45 (2020). However, the Veteran's functional loss must result in limitation of motion sufficient to satisfy the next disability rating allowable for that particular disorder to be entitled to a higher disability rating under §§ 4.40 and 4.45. See Thompson v. McDonald, 815 F.3d 781, 785-86 (Fed. Cir. 2016). Here, the VA examinations and treatment records discussed above note the right knee disability was characterized by pain and limitation of flexion and, while the Veteran argues that his currently assigned 10 percent rating does not consider functional loss due to pain, the evidence of record does not support this argument. Specifically, the Board acknowledges that the multiple VA examinations of record note pain on motion. However, as discussed above, his flexion has never been limited to more than 95 degrees (see again October 2013 VA examination), which is significantly greater than is required for a noncompensable evaluation pursuant to Diagnostic Code 5260. In fact, his currently assigned 10 percent rating specifically contemplates the noted presence of pain and any functional limitations resulting from this disability as he is not entitled to a compensable rating based on his range of motion findings at any point during the appeals period. Thus, the probative evidence does not reflect functional loss that is not already contemplated by the assigned rating of 10 percent. Regarding the holding in Correia, the Board notes the only evidence of pain on weight-bearing was noted in the October 2013 VA Knee and Lower Legs Conditions DBQ, at which time the VA examiner noted the existence of pain on weight-bearing. To this extent, the Board notes that the pain noted on examination is specifically encompassed in the criteria for Diagnostic Code 5260, such that consideration is given to pain in assigning the current 10 percent rating. There is no indication from the objective evidence of record to support a rating in excess of 10 percent due to pain on weight-bearing. Regarding the holding in Sharp, the only reported flare-up was in the August 2019 VA Knee and Lower Legs Conditions DBQ, which was found to be characterized as limitations of prolonged walking. The August 2019 VA examiner also specifically found there was no persistent evidence of record, considered to be valid or reproducible for ratings purposes, that indicates a loss of function during a flare-up. Considering all the evidence of record, the examiner ultimately noted pain, weakness, fatigability or incoordination does not significantly limit functional ability during a flare-up, which would indicate a higher rating is warranted on this basis. In sum, the Board finds that the symptoms noted by the Veteran during his VA examinations are contemplated under the relevant rating criteria and under the Deluca criteria, including §§ 4.40 and 4.45, which compensate for limitation of motion, and symptoms such as pain, weakness, and instability producing functional limitations. C.F.R. 4.40, 4.45, 4.59; Mitchell, 25 Vet. App. at 44 ; Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Moreover, even considering his subjective complaints of pain and other symptoms described in DeLuca, the evidence of record shows that motion of the Veteran’s right knee has been limited to no less than 95 degrees flexion, which is properly rated as 10 percent disabling under Diagnostic Code 5260. In reaching the above conclusions, the Board has not overlooked the Veteran’s statements with regard to the severity of his right knee disability, to include his prior Board hearing testimony and the April 2014 statement from his wife. In this regard, the Veteran and his wife are competent to report on factual matters of which they had firsthand knowledge, e.g., experiencing chronic pain in his knee. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran has provided lay evidence through written statements, his Board hearing testimony, and during his examinations conducted throughout the course of his appeal with respect to the presence of pain and other right knee symptomatology. He is competent to provide such statements, and the Board finds that the Veteran’s statements and those of lay witnesses to be credible. The Veteran’s reported symptomatology has been noted in the several examinations conducted during the appeals period and noted above, and the Board has considered the Veteran’s reports with respect to pain in evaluating his assigned ratings. However, the Board finds that the Veteran is not competent to assign a disability rating as this requires medical expertise and understanding of the musculoskeletal system. Therefore, the medical findings provided by the Veteran’s VA examination reports have been accorded greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (“[t]he probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches... the credibility and weight to be attached to these opinions [are] within the province of the adjudicator.”). Accordingly, as the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Service Connection 2. Right Ankle Disability The Veteran is seeking entitlement to service connection for a right ankle disorder that he believes is due to his military service. Specifically, the Veteran argues that he suffers from a right ankle disorder that is either directly due to service or is due to or aggravated by his service-connected low back disability. See February 2016 Notice of Disagreement; see also August 2015 VA Form 21-526b. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established for a chronic disease as enumerated for VA compensation purposes, to include hypertension, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection for an enumerated “chronic disease” listed under 38 C.F.R. § 3.309(a) can also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In the present case, the record shows the Veteran has been diagnosed with osteoarthritis of the right ankle, according to a January 2018 private treatment record. See August 2019 VA Ankle Conditions DBQ. However, the first noted diagnosis of arthritis was not until the aforementioned 2018 treatment record and not confirmed by x-ray findings. As the August 2019 VA examiner notes, there is no radiographic evidence of arthritis. Further, even if there is a present diagnosis of arthritis, it was not noted until more than 50 years after the Veteran’s separation from service. Therefore, entitlement to presumptive service connection is not warranted. Moreover, even if (arguably) arthritis has been diagnosed, there is no evidence of continuity of symptomatology regarding this disorder as it was first identified in 2018. Therefore, continuity of symptomatology is not for application. See 38 C.F.R. § 3.303; Walker v. Shinseki, 708 F.3d 1331, 1335-36, 1340 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that effective October 10, 2006, 38 C.F.R. § 3.310 was amended; however, under the facts of this case the regulatory change does not impact the outcome of the appeal as the preponderance of the evidence weighs against a finding of a relationship between the Veteran’s claimed disorders and any service-connected disability. As an initial matter, the Board notes the Veteran has been diagnosed with tendonitis of the right ankle. See August 2019 VA Ankle Conditions DBQ. Therefore, the first element of service connection has been satisfied. Next, as to the second element of service connection, the Board notes that the service treatment records are completely silent for any complaints of, treatment for, or a diagnosis of a right ankle disorder during service. Thus, there is no evidence of in-service incurrence on a direct basis, despite the Veteran’s contentions that his right ankle disorder is directly attributable to his military service. Turning to the determinative issue of etiology, and the third element of service connection, the nexus, the Veteran was initially examined by VA in December 2015 in an Ankle Conditions DBQ in connection with his claim for entitlement to service connection. At that time, the VA examiner noted the Veteran did not have an orthopedic condition pertaining to his right ankle, only a neurological disorder associated with his lumbar spine disability. The accompanying January 2016 medical opinion noted that the right ankle complaints are not an orthopedic condition, and any weakness due to a foot drop would be from lumbar radiculopathy. As previously noted, the Veteran’s right ankle drop condition (i.e., neurological condition) is already service connected and, therefore, the Board finds the December 2015 VA examination report and accompanying January 2016 medical opinion contains no additional, probative evidence. There are no other opinions regarding direct service incurrence included in the claims file. Therefore, the medical evidence of record does not support a finding that the Veteran either incurred a right ankle disorder during service, or that he currently has one directly attributable to his military service. Therefore, this part of the claim fails as there is no nexus evidence that would demonstrate that there is a connection between the clamed disorder and his service. Specifically, a right ankle disorder was not noted in service and there has been no showing that it is attributable to his military service on a direct basis. See 38 C.F.R. § 3.303. Turning to the remaining theory of entitlement to service connection on a secondary basis, the Veteran was next scheduled for a VA Ankle Conditions DBQ in August 2019. The VA examiner provided a diagnosis of right ankle tendonitis and ultimately concluded that it is less likely than not the currently diagnosed disorder is proximately due to or the result of the Veteran's service-connected lumbar spine disability. As rationale, the examiner noted the service connection lumbar spine disability with right lower extremity radiculopathy would not be expected to result in an ankle disability such as achilles tendonitis. In June 2020, an addendum opinion was obtained to address whether the right ankle disorder was aggravated by the service-connected lumbar spine disability. The examiner concluded it was less likely than not the right ankle disorder was aggravated by the service-connected lumbar spine disability. As rationale, the examiner noted that lumbar spine problems would cause or aggravate problems in a weight bearing joint, such as ankle, due to long term abnormal gait, which has not been shown by the evidence of record. The examiner further notes that there is no radiographic evidence of arthritis and, even if there were, it is not caused by back problems but rather due to the natural progression of the condition, together with aging. Post-service VA and private treatment records reflect the Veteran’s complaints of pain and treatment for his right ankle disorder during the pendency of the appeal. Specifically, the Veteran submitted private treatment records dated in August 2015 and January 2018 showing evidence of a right foot drop which, again, has already been compensated in the grant of service connection for right lower extremity radiculopathy associated with the lumbar spine disorder. However, there is no evidence in the VA or private treatment records showing a separately diagnosed right ankle disorder that is due to the Veteran’s military service, or secondary to a service connected disability. In fact, the only evidence offered in support of his claim that his right ankle disorder is either due to service, or due to or aggravated by the service-connected lumbar spine disability, are the Veteran’s own statements. To this extent, the Board notes that he is competent to describe the symptoms associated with his disorder, such as pain, which is readily observable by laypersons. Indeed, he has done so during his VA examinations and in the course of treatment for the disorder during the appeal. However, as a lay person, the Veteran has not shown that he has specialized training sufficient to render such an opinion as to the etiology of his diagnosed right ankle disorder. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis and etiology of orthopedic disorders, such as is the case here, requires medical testing to diagnose and medical expertise to determine the etiology. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) (“Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with.”); see Savage v. Gober, 10 Vet. App. 488, 494 (1997) (veteran not competent to provide medical opinion linking present arthritis to in-service fall). Thus, the Veteran’s opinions regarding the etiology of his claimed disorder is not competent medical evidence. The Board finds the opinions of the VA examiners, collectively, to be significantly more probative than the Veteran’s lay assertions, where they are based on their medical expertise and consideration of the Veteran’s medical history. In reaching the above conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (West 2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Entitlement to a TDIU The Veteran contends that he is entitled to TDIU benefits. Based on the evidence of record, the Board finds that entitlement to a TDIU is warranted. A total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. 38 C.F.R. § 3.340 (a)(1). Total ratings are authorized for any disability or combination of disabilities for which the Rating Schedule prescribes a 100 percent evaluation. 38 C.F.R. § 3.340 (a)(2). TDIU 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 a single service-connected disability rated at 60 percent or more; or as a result of two or more service connected disabilities, provided at least one disability is rated at 40 percent or more, and there are additional service connected disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). In Ray v. Wilkie, 31 Vet. App. 58 (2019), the United States Court of Appeals for Veterans Claims (Court) defined the term “unable to secure and follow a substantially gainful occupation” as having two components: one economic and one noneconomic. The economic component means 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. The non-economic component includes consideration of: the Veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. Effective from September 27, 2012, the Veteran has been in receipt of a combined 60 percent rating for his lumbar spine, right and left knee disabilities, and scar of the left knee. In light of the above grant of a separate 20 percent rating for a meniscus condition of the right knee, the Veteran meets the criteria to be eligible for a schedular TDIU under 38 C.F.R. § 4.16 (a),38 C.F.R. § 4.25. In the Veteran’s September 2013 application for a TDIU, VA Form 21-8940, he indicates that he last worked full time in March 1991 as a police officer. He states he is unemployable on account of his service-connected lumbar spine and bilateral knee disabilities and had to take an early retirement. The highest level of education the Veteran has received is four years of high school, and he has not had any other training. In relevant part, both the June 2013 and October 2013 VA Knee and Lower Leg Conditions DBQ examiners determined that the right and left knee disabilities impact employability due to the preclusion of physical labor due to knee pain, and limited walking and standing. It was noted the Veteran may perform sedentary work. A July 2014 VA Back Conditions DBQ examiner concluded the lumbar spine disability impacts the Veteran’s ability to work as he is unable to stand fully erect, which limits his ability to stand for long periods, do overhead work, lift heavy objects, or perform activities requiring twisting of the torso. Further, the recent findings of the August 2019 VA Back Conditions DBQ examiner noted the lumbar spine disability impacted the Veteran’s ability to work due to pain with walking, standing, bending, and lifting. Similarly, the August 2019 VA Knee Conditions DBQ examiner determined the bilateral knee disabilities impacted the Veteran’s ability to work as pain precludes the Veteran from running, prolonged walking, and negotiating stairs. The Board finds that there is competent and probative evidence that shows the Veteran’s lumbar spine and right and left knee disabilities cause him significant physical problems, to include constant pain. While it was noted that he could perform sedentary work, the duties of a police officer, by their very nature, require physicality beyond sitting at a desk. The Board therefore finds that there is adequate and competent evidence indicating that the Veteran’s service-connected disabilities in combination prevent him from being able to maintain any gainful employment. The evidentiary standard for TDIU opinions is not whether the average person would be precluded from substantially gainful employment, but whether the specific Veteran would be so precluded as a result of service-connected disabilities. Thus, when considering this specific Veteran’s disabilities in connection with his employability, the evidence of record establishes entitlement to TDIU. Hence, affording the Veteran the benefit of the doubt, the claim is granted. 38 U.S.C. § 5107 (b). YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Berry, 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.