Citation Nr: 21003152 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 09-09 874 DATE: January 19, 2021 ORDER The application to reopen the claim of entitlement to service connection for tinnitus is granted. Service connection for tinnitus is granted. Service connection for an acquired psychiatric disability, diagnosed posttraumatic stress disorder (PTSD) and alcohol use disorder, is granted. Service connection for obstructive sleep apnea is denied. Service connection for a left shoulder disorder, to include as secondary to service-connected knee disabilities, is denied. Service connection for a right shoulder disorder, to include as secondary to service-connected knee disabilities, is denied. Service connection for a left hip disorder, to include as secondary to service-connected knee disabilities, is denied. Service connection for a right hip disorder, to include as secondary to service-connected knee disabilities, is denied. Service connection for a left ankle disorder, to include as secondary to service-connected knee disabilities, is denied. Service connection for a right ankle disorder, to include as secondary to service-connected knee disabilities, is denied. A rating in excess of 20 percent for patellofemoral syndrome, chondromalacia, and degenerative arthritis of the left knee is denied. A rating in excess of 20 percent for patellofemoral syndrome, chondromalacia, and degenerative arthritis of the right knee is denied. REMANDED Entitlement to service connection for a left elbow disorder, to include as secondary to service-connected knee disabilities, is remanded. Entitlement to service connection for a right elbow disorder, to include as secondary to service-connected knee disabilities, is remanded. Entitlement to service connection for a back disorder, to include as secondary to service-connected knee disabilities, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (hereinafter, TDIU) is remanded. FINDINGS OF FACT 1. In a final decision issued in September 2013, the Agency of Original Jurisdiction denied service connection for tinnitus. 2. Evidence associated with the record since the final denial in September 2013 is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the claim of entitlement to service connection for tinnitus. 3. Resolving all doubt in the Veteran’s favor, his tinnitus is etiologically related to his military noise exposure. 4. Resolving all doubt in the Veteran’s favor, his acquired psychiatric disorders, diagnosed as PTSD and alcohol use disorder, were the result of an in-service stressor. 5. Obstructive sleep apnea is not causally or etiologically related to an in-service event, injury, or illness. 6. A left shoulder disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, nor is it caused or aggravated by a service-connected disability, and arthritis did not manifest to a compensable degree within one year of separation from active duty. 7. A right shoulder disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, nor is it caused or aggravated by a service-connected disability, and arthritis did not manifest to a compensable degree within one year of separation from active duty. 8. A left hip disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, nor is it caused or aggravated by a service-connected disability, and arthritis did not manifest to a compensable degree within one year of separation from active duty. 9. A right hip disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, nor is it caused or aggravated by a service-connected disability, and arthritis did not manifest to a compensable degree within one year of separation from active duty. 10. A left ankle disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, nor is it caused or aggravated by a service-connected disability, and arthritis did not manifest to a compensable degree within one year of separation from active duty. 11. A right ankle disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, nor is it caused or aggravated by a service-connected disability, and arthritis did not manifest to a compensable degree within one year of separation from active duty. 12. For the entire appeal period, the Veteran’s patellofemoral syndrome, chondromalacia, and degenerative arthritis of the left knee was manifested by subjective complaints of pain, popping, grinding, clicking, and giving way with flexion limited to 44 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, recurrent subluxation or lateral instability, dislocated semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 13. For the entire appeal period, the Veteran’s patellofemoral syndrome, chondromalacia, and degenerative arthritis of the right knee was manifested by subjective complaints of pain, popping, grinding, clicking, and giving way with flexion limited to 45 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, recurrent subluxation or lateral instability, dislocated semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. The September 2013 rating decision that denied the Veteran’s claim for entitlement to service connection for tinnitus is final. 38 U.S.C. § 7105(c) (West 2012) [(2012)]; 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2013) [(2020)]. 2. New and material evidence has been received to reopen the claim of entitlement to service connection for tinnitus. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1154, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 4. The criteria for service connection for an acquired psychiatric disorder, diagnosed PTSD and alcohol use disorder, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304. 5. The criteria for service connection for obstructive sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for a left shoulder disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 7. The criteria for service connection for a right shoulder disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 8. The criteria for service connection for a left hip disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 9. The criteria for service connection for a right hip disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 10. The criteria for service connection for a left ankle disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 11. The criteria for service connection for a right ankle disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 12. The criteria for a rating in excess of 20 percent for patellofemoral syndrome, chondromalacia, and degenerative arthritis of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5261. 13. The criteria for a rating in excess of 20 percent for patellofemoral syndrome, chondromalacia, and degenerative arthritis of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1991 to April 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in September 2007 and October 2017 by a Department of Veterans Affairs (VA) Regional Office (RO). The issues of entitlement to service connection for a left shoulder disorder, a right shoulder disorder, a left hip disorder, a right hip disorder, a left ankle disorder, a right ankle disorder and claim for an evaluation in excess of 20 percent for bilateral knee patellofemoral syndrome were previously remanded by the Board for further development in April 2019. Such development was undertaken, and the case is returned to the Board for further consideration. See Stegall v. West, 11 Vet. App. 268 (1998). The evidence of record indicates that the Veteran has been diagnosed with various mental health diagnoses, to include PTSD and anxiety. As such, the Board has recharacterized the claim on appeal as one for an acquired psychiatric disorder. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In a July 2013 VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability (VA Form 21-8940), the Veteran asserted that his bilateral knee disabilities, hip disorder, and back disorder precluded him from substantially gainful employment. Therefore, the Board has assumed jurisdiction over the issue of entitlement to a TDIU as part and parcel of the Veteran’s increased rating claims. Rice v. Shinseki, 22 Vet. App. 447 (2009). Application to Reopen Generally, a claim that has been finally denied in an unappealed RO decision or a Board decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104 (b), 7105(c). The exception is that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence means evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Pursuant to Shade, evidence is considered new if it has not been previously submitted to agency decision makers, and it is material if, when considered with the evidence of record, it would at least trigger VA's duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. The U.S. Court of Appeals for Veterans Claims (Court) interprets the language of 38 C.F.R. § 3.156(a) as creating a low threshold and views the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” The Veteran’s claim for entitlement to service connection for tinnitus was initially denied by the RO in December 2004. In July 2012, the Veteran submitted a request to reopen his claim for entitlement to service connection for tinnitus. A September 2013 rating decision, the Veteran’s claim was not reopened as new and material evidence was not received. The Veteran was notified of this decision and provided with his appellate rights. He did not initiate an appeal by submitting a notice of disagreement, and new and material evidence was not received prior to the expiration of the period in which to appeal. Additionally, relevant service treatment records have not been associated with the record subsequent to the September 2013 rating decision. Therefore, the September 2013 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.105(a), 3.156(b). The pertinent evidence received since the September 2013 denial includes an opinion from the November 2019 VA examiner who determined that the Veteran’s tinnitus was at least as likely as not the result of military noise exposure. This newly submitted evidence pertains to the etiology of the Veteran’s tinnitus, which is an unestablished fact necessary to substantiate the claim. Thus, as this evidence was also not previously reviewed by adjudicators, this testimony constitutes both new and material evidence. As new and material evidence has been received, the claim for service connection for tinnitus is reopened. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as organic diseases of the nervous system and arthritis, to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. When a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for tinnitus. The Veteran is seeking service connection for tinnitus. The Veteran’s DD-214 indicates his military occupational specialty was Airman Apprentice. The Veteran’s service treatment records do not reflect complaints of, treatment for, or a diagnosis referable to tinnitus. Nevertheless, tinnitus is a type of disorder associated with symptoms that are uniquely capable of lay observation. See Charles v. Principi, 16 Vet. App. 370 (2002). As such, the primary role of the Board in adjudicating the tinnitus claim is to assess the credibility of the Veteran’s statements. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Veteran was afforded a VA examination in November 2019, wherein he reported that his tinnitus started in 1993 and had become worse over time. He described his tinnitus as bilateral, constant, and high-pitched. The VA examiner determined that, based on the Veteran’s reported military noise exposure, military occupational specialty with a high probability of hazardous noise exposure, and bilateral significant threshold shift, it was at least as likely as not that his tinnitus is the result of military noise exposure. As there is no evidence of record against a causal relationship between the Veteran’s tinnitus and his military noise exposure, the Board will resolve all reasonable doubt in the Veteran’s favor. Thus, the Board finds that the Veteran’s tinnitus had its onset in service and that it has continued to the present. Accordingly, service connection for tinnitus is granted. 2. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and alcohol use disorder. Service connection for PTSD requires (1) medical evidence diagnosing PTSD in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between a Veteran’s present symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f). The Veteran is seeking service connection for an acquired psychiatric disorder, to include PTSD, which he believes resulted from stressful events he experienced in service. Specifically, the Veteran stated that, while onboard the U.S.S. Kitty Hawk in July 1992, he was connecting a fueling hose to an aircraft when the lock failed and hit him on the back of the knees. He reported that he fell on his tailbone, hit his head on a deck, and his protective gear was knocked off his head. The fuel sprayed on the aircraft and into a running engine. The Veteran stated he was exposed to the rocket pack on the ejection chair without his head gear. Due to his experience, he reported experiencing nightmares of being burned alive, being blown up, or being blown off the flight deck. According to service treatment records, the Veteran sought treatment for a gas explosion in the face in February 1993. In addition, the Board acknowledges that the medical evidence of record provides a diagnosis of anxiety, PTSD, and alcohol use disorder. Specifically, according to the June 2020 VA examination report, a diagnosis of chronic PTSD has been confirmed. According to the May 2020 VA examination report, the Veteran stated that after the stressor event, he was no longer able to “do the same job on the flight deck since it was too traumatic so they switched him to working below deck doing repairs…” He endorsed some anxiety, fear, and increased social isolation. The VA examiner determined that the Veteran’s PTSD and alcohol use disorder were at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner explained: Medical records and this exam support that [V]eteran’s diagnoses of PTSD and alcohol use disorder are at least as likely as not incurred in or caused by the gas tank explosion during service. [The] Veteran presented in this exam as an accurate historian. Medical records support the likelihood that his stressor event took place. This is corroborated by the fact that [V]eteran was granted service connection for knee injuries he sustained from the stated stressor event. Medical records also provide [n]umerous mental health notes going back as far as August 2012 stating that the [V]eteran was experiencing symptoms of PTSD to the point where he met criteria for a diagnosis of PTSD related to the stressor event. [The] Veteran used alcohol as a maladaptive coping mechanism to treat symptoms of PTSD. Here, the Board finds while the Veteran has a diagnosis of an acquired psychiatric disorder, and the VA examiner provided a favorable nexus opinion, the evidence of record does not clearly confirm that the Veteran’s reported stressor occurred. However, based on the Veteran’s in-service treatment records and the VA examiner’s rationale, the Board concludes that the evidence is at least in equipoise as to whether the Veteran’s claimed PTSD stressor occurred. Accordingly, service connection for PTSD and alcohol use disorder is warranted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304(f)(5), 4.125(a). 3. Entitlement to service connection for obstructive sleep apnea. The Veteran claims his current obstructive sleep apnea is related to his military service. Service treatment records do not indicate any complaints, treatment, or diagnosis of any problems with sleep disturbances during military service. The Veteran’s post-service treatment records confirm he has a diagnosis of obstructive sleep apnea. There is, however, no indication in the evidence of record that this condition stems from his military service or is due to a service-connected disability. In this regard, the Veteran has not submitted any medical evidence that suggests he has sleep disorder as a result of his military service, or any injury therein. In fact, the Veteran has not provided any lay statements concerning his symptomatology, whether in service or post-service. As a lay person, the Veteran is competent to report what comes to him through his senses, but the evidence does not show he has the medical training and expertise to provide a complex medical opinion, such determining the etiology of obstructive sleep apnea. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Therefore, while the Veteran disagrees with the conclusion that his obstructive sleep apnea neither began during, nor was otherwise caused by, his active service, he is not considered competent (meaning medical qualified) to address the etiology of this condition. As such, his opinion is insufficient to provide the requisite nexus. There is nothing in the record, outside of the Veteran’s statements, that would suggest that his current obstructive sleep apnea had its onset in service. The earliest clinical evidence of obstructive sleep apnea appeared over twenty years after separation from service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. Consequently, the Board finds the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for obstructive sleep apnea. There is no doubt to be resolved, and his claim must be denied. 4. Entitlement to service connection for a left shoulder disorder, to include as secondary to service-connected knee disabilities. 5. Entitlement to service connection for a right shoulder disorder, to include as secondary to service-connected knee disabilities. 6. Entitlement to service connection for a left hip disorder, to include as secondary to service-connected knee disabilities. 7. Entitlement to service connection for a right hip disorder, to include as secondary to service-connected knee disabilities. 8. Entitlement to service connection for a left ankle disorder, to include as secondary to service-connected knee disabilities. 9. Entitlement to service connection for a right ankle disorder, to include as secondary to service-connected knee disabilities. The Veteran contends that service connection is warranted for his bilateral shoulder, hip, and ankle disabilities secondary to his service-connected bilateral knee disabilities. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Additionally, when aggravation of a Veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). Service treatment records do not reflect any complaints, treatment, or diagnosis of any bilateral shoulder, hip, and ankle disabilities. The Veteran was afforded a VA examination in September 2014, wherein the VA examiner provided diagnoses of shoulder strain, bilateral mild degenerative joint disease, and a right ankle strain. Mild degenerative changes in the shoulder and ankles were noted. The VA examiner determined that it was less than likely that the bilateral shoulder, hip, and ankle disabilities were proximately due to, or the result of, the Veteran’s service-connected condition. The VA examiner explained that the arthritis of the knee does not cause shoulder dysfunction, even in the event of repetitive pushing to relieve pressure on the knees when standing up. The VA examiner stated that while the Veteran does have bilateral shoulder strain/degenerative changes on X-ray, it was more likely caused by the natural aging process, not his service-connected knees. Regarding the bilateral hips and ankles, the VA examiner explained that a review of the medical literature did not support the theory that degenerative joint disease causes degenerative joint disease in another. The Veteran had a normal hip physical examination and the incidental X-ray findings of mild bilateral hip and ankle degenerative joint disease are more likely than not related to the natural aging process. In April 2019, the Board found that while the VA examiner addressed whether the Veteran’s bilateral shoulder, hip, and ankle disabilities were caused by service-connected knee disabilities, she did not address the theory of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Accordingly, a Remand was required for an additional opinion. In November 2019, a VA examiner determined that the disabilities were less likely than not proximately due to, or the result of, the Veteran’s service-connected condition. The VA examiner explained that the “medical literature [did] not support the theory that dysfunction in one joint causes dysfunction in another or aggravates another joint’s condition.” The bilateral arthritis in the shoulder is more likely a function of the natural aging process, and it was not caused or aggravated by the Veteran’s service-connected bilateral knees. Regarding the bilateral hips and ankles, the VA examiner stated, “the medical literature shows that dysfunction in one joint rarely causes dysfunction in another, or aggravates another, except when damage/injury results in a major displacement of the center of gravity of the body while walking, or significant shortening of the injured extremity (>5 cm).” Here, there was no evidence, based on observation and physical examination findings, that this had occurred. The VA examiner cited to a medical treatise to support this determination. After a review of the evidence of record, the Board finds that the Veteran’s claims must be denied. As opined by the VA examiner, the Veteran’s bilateral shoulder, hip, and ankle disabilities are not secondary to, or aggravated by, his service-connected knee disabilities. Furthermore, the Veteran has not provided probative evidence of a nexus between his bilateral shoulder, hip, and ankle disabilities and his active duty service. The VA treatment records do not show any etiological relationship between the Veteran’s disabilities and his military service. There was no other competent evidence that contradicts this finding, specifically, that it stemmed from his military service. Here, the Board affords significant probative value to the VA examiner’s opinions, when considered together. All available, pertinent medical information was presented to, and considered by, the VA examiner. The VA examiner also conducted a thorough review of the evidence of record, to include the Veteran’s lay statements regarding his current disabilities, and performed physical examination of the Veteran. The Board acknowledges the Veteran’s contentions that his disabilities are related to military service or, in the alternative, his service-connected knees disabilities. The Veteran is considered competent to report the observable manifestations of his claimed disabilities. 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 etiologies of such disorders involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, such matters may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In the instant case, the evidence does not show the Veteran has the medical training and/or knowledge to address such complex medical questions and, thus, his statements concerning the etiologies of his current disorders is not afforded probative weight. Moreover, consistent with the medical evidence and VA examination reports, arthritis did not manifest within one year of the Veteran’s discharge from service. The Board also has considered the Veteran’s lay statements in light of establishing service connection on the basis of continuity of symptomatology. However, the Veteran consistently reports the onset of his bilateral shoulder, hip, and ankle disorders secondary to bilateral knee pain years after service. Based on the foregoing, the Board finds a bilateral shoulder disorder, bilateral hip disorder, and bilateral ankle disorder are not shown to be causally or etiologically related to any disease, injury, or incident during service. In addition, the evidence does not show such disorders were caused or aggravated by a service-connected disability, and arthritis did not manifest to a compensable degree within one year of separation from active duty. Consequently, service connection for such disorders is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s service connection claims, to include on a secondary basis. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Increased Ratings 1. Entitlement to a rating in excess of 20 percent for patellofemoral syndrome, chondromalacia and degenerative arthritis, left knee. 2. Entitlement to a rating in excess of 20 percent for patellofemoral syndrome, chondromalacia and degenerative arthritis, right knee. The Veteran is in receipt of 20 percent ratings under Diagnostic Code 5010-5260 for his right and left knee disabilities. He contends increased disability ratings are warranted. The appeal period before the Board stems from the receipt of the Veteran’s informal increased rating claims on January 25, 2007, to include consideration of the one-year look back period. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). Diagnostic Code 5010 (traumatic arthritis) provides that degenerative arthritis should be rated as arthritis, degenerative. Diagnostic Code 5003 (arthritis, degenerative) provides that arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on x-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. The general rating schedules for limitation of motion of the knee are set forth in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees, and a 30 percent disability rating is assigned for flexion limited to 15 degrees. Under Diagnostic Code 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5257 provides the rating criteria for impairment of the knee manifested by recurrent subluxation and lateral instability. Under this diagnostic code provision, a 10 percent disability rating is warranted where there is slight recurrent subluxation or lateral instability of the knee. A 20 percent disability rating is warranted where the recurrent subluxation or lateral instability of the knee is moderate. The maximum 30 percent disability rating is warranted where there is severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Turning to the evidence of record, the Veteran was afforded a VA examination in June 2007, wherein he stated that his knees hurt daily and that during flare-ups, which were precipitated by stepping up, his knees became swollen once a week. He experienced cracking and popping. In addition, his knees gave way twice a week, but he did not fall. The Veteran reported that no impact on his occupational functioning but an inability to weightlift, bicycle, or jog. Physical examination revealed a slight limp of the left knee. There was tenderness on the right knee, laterally, but otherwise no tenderness on the left. The cruciate and collateral ligaments were stable and there was no instability. There was no evidence of effusion and palpation of the knees with active motion rubbing palpated on the right and left on extension. Muscle strength testing was normal and there was no fatigability. Range of motion testing on the right knee revealed extension at 0 degrees and flexion at 58 degrees. The range of motion testing on the left knee revealed extension at 0 degrees and flexion at 80 degrees. There was no additional limitation on repeated use. The VA examiner diagnosed mild degenerative joint disease (DJD) resulting in moderately severe functional impairment of the right knee and at least moderate functional impairment of the left knee. There was no evidence of weakness or fatigability, bilaterally. There was no evidence of incoordination on the right knee but there was slight incoordination/limp on the left knee. The Veteran underwent additional VA examination in July 2008, wherein he stated he had progressively severe pain and dysfunction with his knees giving way on a daily basis if he did not wear his braces. They locked daily and the pain and dysfunction were equal in both knees. He had constant, bilateral knee pain with daily pain lasting two hours. He reported that he mostly sat or laid down, and his maximum walking distance was 1/8 of a mile. He had to sit after standing for 15 minutes. Furthermore, the Veteran stated he had difficulty kneeling, squatting, stair-climbing, and running, and he no longer played sports. On examination, he had an antalgic gait without assistive devices, limping on both legs, but he was able to move about the examining room, mount and dismount the examining table, and rise from the supine to sitting position on his own. The bilateral knees revealed positive patellar grind, apprehensive, positive McMurray testing, negative Lachman test, and no lateral instability. The range of motion on the left knee was 0 degrees extension and 44 degrees flexion. After three repetitions, the range of motion was 0 degrees extension and 45 degrees flexion. The range of motion on the right knee was 0 degrees extension and 50 degrees flexion. After three repetitions, the range of motion was 0 degrees extension and 45 degrees flexion. The major functional impact of both knees was pain rather than weakness, fatigue, lack of endurance, or incoordination. According to a January 2014 VA examination report, the diagnoses of bilateral patellofemoral syndrome, chondromalacia patella, and DJD were confirmed. The Veteran stated his knees were getting worse and that they popped and grinded constantly. He had no knee surgeries but was told that eventually he would knee replacement. He took ibuprofen PRN for pain but stated that it helped only a little. He tried to perform non-impact exercises to “keep my legs strong” and reported that he had lost some weight with beneficial effect on knee pain. The Veteran stated his flare-ups did not impact the functioning of the knees. Range of motion testing revealed flexion at 90 degrees on the right knee and 80 degrees on the left knee, with pain on both. The Veteran had 0 degrees of extension with pain, bilaterally. The ranges of motion after repetitive-use testing in the right knee revealed 90 degrees flexion and 0 degrees extension. The ranges of motion after repetitive-use testing in the left knee revealed 80 degrees flexion and 0 degrees extension. The Veteran did not have additional limitation in range of motion following repetitive use testing. He had functional loss and/or functional impairment of the knee which included less movement than normal; incoordination, impaired ability to execute skilled movements smoothly; pain on movement; disturbance of locomotion; and interference with sitting, standing, and weight-bearing. The Veteran had tenderness or pain to palpation for joint line or soft tissue of both knees. Muscle strength testing and joint stability testing revealed normal findings. There was no evidence of history of subluxation/dislocation, “shin splits,” stress fractures, chronic exertional compartment syndrome, any other tibial and/or fibular impairment, or meniscal condition or surgical procedures for a meniscal condition. The Veteran has not had joint replacement or other surgical procedures, scars, or other pertinent physical findings, complications, conditions, signs and/or symptoms related to his bilateral knee disabilities. The Veteran wore braces, regularly. The Veteran did not have functional impairment of the bilateral knees such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. X-rays did not reveal evidence of patellar subluxation. The Veteran stated he was no longer able to work in the automotive industry as it was too physically strenuous on his knees. He was currently employed in aviation management, which required some light walking that he was able to do. The VA examiner determined that the Veteran would not be able to do any physically demanding job that required running, walking more than 15 minutes at a time, lifting, or squatting. The VA examiner stated that there was insufficient evidence or objective exam findings that would provide a reliable prediction of decreased functional ability during flare-ups or when the knee joints were used repeatedly over a period of time. Therefore, the VA examiner stated that based on the available evidence and exam findings, it was not possible, without resorting to speculation, to predict within a reasonable degree of medical certainty, a potential loss of range of motion manifested as a consequence of a flare or exacerbation outside the clinical setting. In October 2017, the Veteran underwent another VA examination, wherein he stated that since the prior examination, he experienced increased pain and more stiffness in both knees. His knees clicked, locked, popped, and swelled from time to time. He tried to perform home exercises, although he experienced increased difficulty in doing so. He participated in a course of physical therapy and had been taking ibuprofen as needed. The Veteran did not report flare-ups of the knees. The Veteran stated the pain and stiffness in both knees prevented him from biking or running. Range of motion testing revealed 100 degrees flexion and 0 degrees extension, bilaterally, which contributed to functional loss making it difficult to squat. Pain was noted on flexion and extension, which caused functional loss. There was evidence of pain with weight bearing and objective evidence of localized tenderness or pain on palpation of the knee joint. The medical and lateral joint line tenderness to moderate palpation attributed to the Veteran’s knee disabilities. There was objective evidence of crepitus. The Veteran was able to perform repetitive-use testing, bilaterally, with at least three repetitions without additional functional loss or range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time as the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. The pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. Muscle strength testing was normal, bilaterally, and there was no history of recurrent subluxation or lateral instability. There was also no evidence of ankylosis or joint instability. There was a history of swelling in the right knee which the VA examiner also noted on the physical examination. The Veteran wore braces constantly. There was no evidence of history of subluxation/dislocation, “shin splits,” stress fractures, chronic exertional compartment syndrome, any other tibial and/or fibular impairment, or meniscal condition or surgical procedures for a meniscal condition. The Veteran has not had joint replacement or other surgical procedures, scars, or other pertinent physical findings, complications, conditions, signs and/or symptoms related to his bilateral knee disabilities. The Veteran did not have functional impairment of the bilateral knees such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. X-rays did not reveal evidence of patellar subluxation but did have degenerative arthritis. The VA examiner stated that the Veteran’s bilateral knee disabilities would limit prolonged walking, standing, and prevented squatting, running, climbing, and crawling. Finally, the VA examiner noted that the contralateral joint was uninjured/normal, bilaterally, and there was no pain with non-weight bearing noted on examination. It was noted that the pain with passive range of motion was not determined as testing could not be performed or was not medically appropriate. The VA examiner also noted that the Veteran had pain with weight bearing, bilaterally, which limited prolonged walking, standing, and prevented running. The Veteran’s treatment records during the appeal period have been reviewed but do not show any results that differ from the results found at the VA examinations discussed above. After review of the evidence of record, the Board finds ratings in excess of 20 percent for the bilateral knee disabilities are not warranted under Diagnostic Codes 5260 or 5261. As indicated above, the Veteran’s service-connected knee disabilities are assigned 20 percent ratings under Diagnostic 5010-5260 based on limitation of flexion. To warrant a higher rating, the Veteran must show limitation of flexion at least to 15 degrees. There is no evidence to show that the Veteran’s right knee or left knee flexion is limited to 15 degrees during the appeal period. At worse, the Veteran’s flexion was 44 degrees in the left knee and 45 degrees in the right knee. As there is no medical evidence of record demonstrating limitation of flexion to 15 degrees, higher 30 percent disability ratings for the bilateral knee disabilities are not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Further, the Board notes that separate compensable ratings could be assigned if extension was shown to be functionally limited to 10 degrees or less. Throughout the period on appeal, however, the evidence does not suggest that extension of the bilateral knees was limited at all, as he has been able to fully extend his knees at all VA examinations. As there is no medical evidence of record demonstrating limitation of extension, separate ratings based on limitation of extension are not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. As for any separate compensable rating for bilateral knee instability, there is no objective evidence of lateral instability or recurrent subluxation of either knee. Although the Veteran reported that his knees gave out during the June 2007 and July 2008 VA examinations, the VA examiners have not found joint instability, bilaterally. Joint stability testing was also normal at the January 2014 and October 2017 VA examinations. There was no evidence or history of recurrent patellar subluxation/dislocation. In this regard, while the Veteran is competent to describe feelings of instability, he is not competent to relate such symptoms to a diagnosis of recurrent subluxation or lateral instability. Here, there is no indication that he possesses the requisite knowledge to administer or interpret specialized testing that would reveal subluxation or instability. See Woehlaert, 21 Vet. App. 456. The VA examiners, who have the training to conduct and interpret patellar and ligament testing, found that there was no subluxation or laxity in the knees. Therefore, the Board finds the record does not demonstrate evidence of recurrent subluxation or lateral instability in order to warrant a higher and/or separate rating under Diagnostic Code 5257. The Board has also considered whether the Veteran is entitled to any additional ratings for his knee disabilities. The clinical evidence does not establish ankylosis, removal or dislocation of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. Therefore, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 are not for application. Furthermore, the Board finds that the Veteran’s subjective symptomatology are contemplated by his currently assigned 20 percent ratings under Diagnostic Code 5260. See 38 C.F.R. § 4.14; Esteban, supra. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record with respect to the claims decided herein. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to service connection for a left elbow disorder, to include as secondary to service-connected disabilities, is remanded. 2. Entitlement to service connection for a right elbow disorder, to include as secondary to service-connected disabilities, is remanded. The Veteran contends that his left and right elbow disorders are the result of his military service. Alternatively, he asserts such disorders are secondary to his service-connected knee disabilities as he had to lift himself in and out of chairs. The Veteran was afforded a VA examination for these disabilities in October 2017, wherein a diagnosis of osteoarthritis of the bilateral elbows was confirmed. The VA examiner, however, determined that it was less likely than not that these were caused by the claimed in-service injury, event, or illness. The VA examiner explained that the service treatment records were reviewed but there was “a lack of objective evidence of a chronic, pathologic right or left elbow condition occurring in the service or diagnosed in the service or due to service.” Furthermore, the VA examiner stated that “[m]ore likely, the degenerative changes in the elbows are due to changes associated with the normal process of aging.” Upon review, the Board finds an addendum opinion is necessary to address the question of whether the Veteran’s current bilateral elbow disabilities are proximately due to, or aggravated by, his service-connected bilateral knee disabilities. Thus, a remand is warranted. 3. Entitlement to service connection for a back disorder, to include as secondary to service-connected knee disabilities, is remanded. The Veteran contends that a current back disorder is related to his military service. In the alternative, he asserts such is secondary to his service-connected knee disabilities. X-ray examination in October 2017 revealed multilevel mild spondylosis of the lumbar spine, including suggestion of disc disease at L4-L5 and L5-S1. An August 2020 VA treatment record also indicates the Veteran’s chronic mechanical back and knee pain were secondary to degenerative changes and resulted in spasms, deconditioning, and abnormal posturing. Furthermore, the Veteran submitted a medical article discussing the relationship between limping and back pain. Based on this evidence, the Board finds a remand is warranted for a VA examination and etiological opinion prior to appellate review. 4. Entitlement to a TDIU. As noted above, the Veteran raised the issue of entitlement to a TDIU, citing to the reported impact of the service-connected bilateral knee disabilities, hip disorder, and back disorder. As a result, such claim is inextricably intertwined with the latter claim remanded herein and adjudication must be deferred pending the development and readjudication of such claim. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Further, while on remand, the AOJ should conduct any indicated development in regard to such claim. The matters are REMANDED for the following actions: 1. Return the claims file to the October 2017 VA examiner who conducted the VA examinations for the Veteran’s bilateral elbow disabilities and rendered the related nexus opinions. If the October 2017 VA examiner is no longer available, the opinion should be rendered by another medical professional. If an opinion cannot be provided without an examination, one should be provided. The VA examiner should answer the following questions: (a.) Is it at least as likely as not (50 percent or greater) that the Veteran's bilateral elbow disabilities were caused by his service-connected knee disabilities? (b.) Is it at least as likely as not (50 percent or greater) that the Veteran's bilateral elbow disabilities were aggravated (i.e., made worse) by the Veteran’s service-connected knee disabilities? If aggravation is found, the VA examiner must identify the baseline level of severity of the bilateral elbow disabilities by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the bilateral elbow disabilities. If this cannot be done, it should be explained why. The VA examiner is asked to consider and address the Veteran’s lay statements regarding his disabilities, i.e., that his elbows disabilities were the result of lifting himself in and out of chairs as a result of his bilateral knee disabilities. A complete rationale should be provided for any opinion offered. 2. Schedule the Veteran for an appropriate examination to determine the nature and etiology of any current back disorder. Following a review of the record and all necessary testing, the examiner should address the following: (A) Identify all current back disorder(s) and address all diagnoses found in the treatment records, to include multilevel mild spondylosis of the lumbar spine. (B) For each currently diagnosed back disorder, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder had its onset in, or is otherwise related to, the Veteran’s military service. (C) For each currently diagnosed back disorder, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder is proximately due to and/or aggravated by a service-connected disability. For any aggravation found, the examiner should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. The examiner also must address the medical literature submitted by the Veteran discussing a relationship between limping and back disorders. A complete rationale should be provided for any opinion offered. M. M. Celli Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Yoo, 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.