Citation Nr: 21063782 Decision Date: 10/15/21 Archive Date: 10/15/21 DOCKET NO. 17-41 141 DATE: October 15, 2021 ORDER An initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. An initial rating in excess of 20 percent for right shoulder disability including acromioclavicular (AC) joint osteoarthritis is denied. An initial rating in excess of 10 percent for left knee patellofemoral pain syndrome is denied. An initial rating in excess of 10 percent for right knee patellofemoral pain syndrome is denied. Entitlement to service connection for left and right foot disability is denied. Entitlement to service connection for gastrointestinal disability is denied. Entitlement to service connection for disability claimed as pain in the right side is denied. FINDINGS OF FACT 1. The Veteran's PTSD was not shown to cause occupational and social impairment with deficiencies in most areas. 2. The Veteran's right disability including AC joint osteoarthritis results in pain but is not shown to have nonunion or dislocation of the clavicle or scapula, a humerus impairment, ankylosis, or limitation of motion functionally limited to less than at shoulder level. 3. The Veteran's left knee disability was not productive of actual or functional flexion limited to 30 degrees, actual or functional extension limited to 5 degrees, even with consideration of additional functional loss due to pain; ankylosis, impairment of the tibia and fibula, or genu recurvatum have not been demonstrated. 4. The Veteran's right knee disability was not productive of actual or functional flexion limited to 30 degrees, actual or functional extension limited to 5 degrees, even with consideration of additional functional loss due to pain; ankylosis, impairment of the tibia and fibula, or genu recurvatum have not been demonstrated. 5. The preponderance of the evidence of record is against finding that the Veteran has a diagnosed left or right foot disability. 6. The preponderance of the evidence of record is against finding that the Veteran has a diagnosed gastrointestinal disability. 7. The preponderance of the evidence of record is against finding that the Veteran has a diagnosed disability claimed as pain in the right side. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a rating in excess of 20 percent for a left shoulder disability have not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5200-03. 3. The criteria for a rating in excess of 10 percent for left knee disability based on limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261. 4. The criteria for a rating in excess of 10 percent for right knee disability based on limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261. 5. The criteria for service connection for gastrointestinal disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303. 6. The criteria for service connection for pain in right side have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303. 7. The criteria for service connection for left and right foot disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 2002 to June 2007, to include service in Iraq. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September and November 2016 rating decisions issued by the Agency of Original Jurisdiction (AOJ). This matter was previously before the Board in April 2019 where it was remanded for additional evidentiary development. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. With the initial rating assigned with the award of service connection for a disability, "staged" ratings to reflect distinct periods when different levels of impairment were shown are for consideration. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). However, the evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 1. Entitlement to an initial rating in excess of 50 percent for PTSD. By rating decision of September 2016, service connection for PTSD was granted with an initial rating of 50 percent effective June 23, 2016, the date VA received the Veteran's original claim. The Veteran disagrees with the rating assigned and seeks an increased evaluation for his PTSD. The Veteran's PTSD has been rated under Diagnostic Code 9411, which is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula for Mental Disorders, a 50 percent rating requires occupational and social impairment, but with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted for even greater occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. When rating a mental disorder, VA must consider the frequency, severity, and duration of the Veteran's psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency must assign a rating based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When rating the level of disability from a mental disorder, the rating agency must consider the extent of social impairment but cannot assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. The Veteran's actual symptomatology, and resulting social and occupational impairment, will be the primary focus when assigning a disability rating for a mental disorder, and the Veteran may qualify for a particular rating by demonstrating the particular symptoms associated with that percentage, or other symptoms of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). As will be explained below, the Board concludes that an evaluation exceeding 50 percent is not supported and a higher rating is not warranted. The Veteran was afforded a VA contract examination in September 2016. The examining psychologist confirmed a diagnosis of PTSD. The Veteran's level was indicated as, "Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or symptoms controlled by medication." The examiner indicated symptoms of anxiety, suspiciousness, difficulty in establishing and maintaining effective work and social relationships and impaired impulse control, such as unprovoked irritability with periods of violence. On clinical interview, the Veteran reported being married with two children. He has a fair relationship with his father and sister. He reported currently being employed full time involved with data management and satellite communications at the Naval Surface Warfare Center. The examiner observed the Veteran to be a reliable historian. See Initial PTSD DBQ dated September 2016. In compliance with the Board's April 2019 remand, the Veteran was afforded another VA examination in November 2019. The examiner indicated a current diagnosis of PTSD and determined the level of impairment as, "A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication." The Veteran reported that his symptoms have not changed much since the last exam. He reported maintaining contact with his siter and father, mother passed away 5 years-ago. He reported being married in 2003, have daughter and son, all live together in a home they own. The family takes vacations on occasion and an occasional date night. He reported working at the Naval Surface Warfare Center fulltime since 2007. The examiner indicated symptoms of anxiety, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships and impaired impulse control, such as unprovoked irritability with periods of violence. The See Review PTSD DBQ dated November 2019. Upon review of the evidence, the Board finds that the preponderance of the evidence is against a finding of entitlement to an evaluation exceeding 50 percent at any time during the appeal period. As demonstrated above, the Veteran clearly experienced psychiatric symptomatology as a result of his PTSD with symptoms such as anxiety, suspiciousness, ongoing symptoms of frustrations, anger, and avoidance as well as chronic sleep impairment. However, the objective evidence of record does not establish that his PTSD was manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, there is no evidence to so that at any time during the appeal period the Veteran reported any history of suicidal/ homicidal ideation, any recurrent thoughts of death, recent passing/active suicidal ideations, or suicidal intentions. In fact, the Veteran consistently denied suicidal ideation, attempts/gestures, or psychiatric admissions, and denied homicidal thoughts, mania or psychotic symptoms. See Initial PTSD DBQ dated September 2016 and Review PTSD DBQ dated November 2019. Additionally, the Board has taken into consideration the frequency, severity, and duration of the Veteran's symptoms of PTSD, as well as his statements regarding his assessment of the severity of his symptoms. However, the symptoms present here, and their resulting effects, do not rise to the level of the next higher 70 percent rating. Further, it is not just the presence of psychiatric symptoms that mandates the assignment of a higher rating, but rather, the Board must evaluate how the reported symptoms impact the Veteran's occupational and social functioning. Vazquez-Claudio, 713 F.3d at 117. Regard to Veteran's occupational and social functioning, the record reflects that he remains married, enjoys leisure activities, and has maintained full-time employment since 2007. Furthermore, at no time does the record reflect that he had an inability to establish and maintain effective relationships. Notably, the recent November 2019 VA Psychologist determined the Veteran's level of occupational and social impairment as, "A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication." Consequently, the Veteran's PTSD was not shown to cause occupational impairment with deficiencies in most areas, which is required for the next higher 70 percent rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. In sum, the Board finds that the Veteran's PTSD symptoms during the entire appeal period do not impact his social and occupational functionality in such a way to result in social and occupational impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. As such, the Board concludes that the Veteran's PTSD has not been manifested by symptomatology more nearly approximating the criteria for a 70 percent disability rating under 38 C.F.R. § 4.130, Diagnostic Code 9411, and an initial rating in excess of 50 percent is not warranted. 2. Entitlement to an initial rating in excess of 20 percent for right shoulder disability. By rating decision of November 2016, service connection for right shoulder AC joint osteoarthritis was granted with an initial evaluation of 20 percent effective June 23, 2016, the date of original claim. The Veteran disagrees and generally contends entitlement to higher rating for his right shoulder disability. The Veteran's right shoulder disability is evaluated under Diagnostic Code 5010-5201. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. The Veteran is right-handed and therefore, his right shoulder is the major upper extremity. Diagnostic Code 5010 indicates that arthritis due to trauma, substantiated by x-ray findings are rated as arthritis, degenerative. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Under Diagnostic Code 5003, degenerative 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 (here, Diagnostic Codes 5201 and 5203 for the shoulder and arm). 38 C.F.R. § 4.71a, Diagnostic Code 5003. When however, the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Effective February 7, 2021, VA amended Diagnostic Code 5010, indicates post-traumatic arthritis is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with §4.25. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Effective February 7, 2021, VA amended Diagnostic Code 5201 to reflect that limitation of motion may be shown by flexion and/or abduction and clarified the degrees of limitation of motion that correspond to each rating. Now, limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Flexion and/or abduction limited to 25 degrees from the side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. Normal forward flexion of the shoulder is 0 to 180 degrees; abduction is 0 to 180 degrees; and internal and external rotation are from 0 to 90 degrees. 38 C.F.R. § 4.71a, Plate I. Forward flexion and abduction to 90 degrees amounts to shoulder level. Diagnostic Code 5203 evaluates impairment of the clavicle or scapula. Under Diagnostic Code 5203, a 10 percent rating is assigned for malunion of the clavicle or scapula. A 20 percent rating is assigned for nonunion of the clavicle or scapula with loose movement or dislocation of the clavicle or scapula. Turning to the evidence, the Veteran was afforded a VA examination in October 2016. The examiner indicated diagnoses of AC arthritis of the right shoulder, impingement rotator cuff tendinitis and subacromial bursitis. Initial range of motion was 90 degrees of flexion and abduction to 90 degrees with evidence of painful motion. He had normal range for external rotation and internal rotation. There was evidence of painful motion which caused functional loss. Range of motion was the same with repetitive use testing. He retained normal strength of 5/5 with no reduction in muscle strength of the right shoulder. There was no evidence of muscle atrophy. Tests for rotator cuff condition for the right shoulder were positive. The examiner indicated impairment of the clavicle or scapula as right shoulder dislocation and impingement of the AC joint with tenderness on palpation of the AC joint on both shoulders. Cross-body adduction test was positive for both sides. The examiner indicated that the clavicle or scapula affected range of motion. There was no impairment of the humerus. See Shoulder and Arm Conditions DBQ dated October 2016. In compliance with the Board's April 2019 remand, the Veteran was afforded another VA examination in November 2019. The examiner indicated diagnoses associated with the right shoulder as shoulder impingement syndrome, rotator cuff tendonitis, and AC joint osteoarthritis. Initial range of motion was 170 degrees of flexion and abduction. Although pain was noted on exam, the examiner indicated it does not result in/cause functional loss. Range of motion was the same with repetitive use testing. He retained normal strength of 5/5 with no reduction in muscle strength of the right shoulder. There was no evidence of muscle atrophy. There was no impairment of the clavicle or scapula indicated or evidence of tenderness on palpation of the AC joint. There was no impairment of the humerus. See Shoulder and Arm Conditions DBQ dated November 2019. As explained below, the preponderance of the evidence is against the finding of an increased rating for right shoulder disability. The Board finds that an initial rating in excess of 20 percent based on limitation of motion is not warranted. The evidence shows the Veteran demonstrated right shoulder range of motion more than shoulder level and, at worst, was 90 degrees of flexion and abduction. See VA examinations dated 2016 and 2019. The Board acknowledges the Veteran's lay reports of symptoms of functional loss due to pain, including difficulty or inability to perform work overhead. However, even considering the Veteran's lay reports of symptoms and functional loss, there remains no indication he suffers a more severe disability picture warranting a rating in excess of 20 percent for limitation of motion. In fact, the degree of additional limitation reflected by the statements would not result in symptoms more nearly approximating flexion and/or abduction limited to 45 degrees for the major extremity, which is required for the next higher 30 percent rating under Diagnostic Code 5201. Moreover, as the Veteran is already in receipt of a 20 percent evaluation for his right shoulder disability, based upon a hyphenated code directing to range of motion, an additional evaluation based upon painful motion is not warranted. 38 C.F.R. §§ 4.40 and 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). Here, even when considering pain, the Veteran retained range of motion in excess of that contemplated for a 20 percent rating. Further, repetitive use testing did not result in additional limitation of motion and the examiners indicated that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repetitive use over a period of time. His currently assigned rating compensates for pain as he is assigned a 20 percent based on limitation of motion and a separate rating for AC joint arthritis. Thus, greater ratings for limitations of range of motion are not warranted under DeLuca. As such, there is no basis for higher ratings. Lastly, the Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. Diagnostic Code 5200 provides for the evaluation of a shoulder or arm disability if there is ankylosis of the scapulohumeral articulation. However, as discussed above, as there is no evidence that the Veteran has ankylosis of the right shoulder, Diagnostic Code 5200 is not for application. Shoulder disabilities may also be evaluated pursuant to Diagnostic Code 5202, as other impairment of the humerus. However, the Veteran does not have loss of head, nonunion, or fibrous union of the humerus, and there was no malunion of the humerus with moderate or marked deformity. Thus, Diagnostic Code 5202 is not for application. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for an initial rating in excess of 20 percent for right shoulder disability. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; as the preponderance of the evidence is against assignment of any other higher ratings, it is not applicable. 38 U.S.C. § 5107. 3. A rating in excess of 10 percent for left knee patellofemoral pain syndrome. 4. A rating in excess of 10 percent for right knee patellofemoral pain syndrome. By rating decision of November 2016, service connection for left knee patellofemoral pain syndrome and assigned an initial rating of 10 percent under Diagnostic Code 5260. Service connection for right knee patellofemoral pain syndrome was also granted with an initial rating of 10 percent under Diagnostic Code 5260, effective June 23, 2016, the date of original claim. The Veteran disagrees and generally contends entitlement to higher ratings for his bilateral knee disability. The Veteran's knee disability is rated under Diagnostic Code 5260 based on limited flexion. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. Diagnostic Codes 5260 and 5261 pertain to limitation of knee motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5260, limitation of flexion of the leg at the knee is rated at 10 percent if limited to 45 degrees, at 20 percent if flexion is limited to 30 degrees, and at 30 percent when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limitation of extension of the leg at the knee is rated at 0 percent if limited to 5 degrees, at 10 percent if limited to 10 degrees, 20 percent if limited to 15 degrees, at 30 percent when extension is limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. VA regulations provide that "pyramiding," or evaluation of the same disability under various diagnoses, is to be avoided. 38 C.F.R. § 4.14. Separate ratings for knee disabilities may be assigned for disability of the same joint if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04 (2004); 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14. Separate ratings must be based on additional disability. Additionally, Diagnostic Codes 5256 and 5257 are not for application as there is no evidence of ankylosis, recurrent subluxation or lateral instability at any point during the appeal period. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5257. Likewise, Diagnostic Code 5258 is not for application as the evidence does not show dislocated semilunar cartilage with frequent episodes of joint "locking," pain, and effusion into the joint as required. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Diagnostic Code 5259 does not apply as there is no evidence of removal of symptomatic semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Diagnostic Codes 5262 or 5263 are not for application as there is no evidence of tibia and fibula impairment, or genu recurvatum at any point during the appeal. See 38 C.F.R. § 4.71a, Diagnostic Codes 5262, 5263. In conjunction with his claim, the Veteran was afforded a VA examination in October 2016, which was conducted by a VA Orthopaedic Surgeon. On range of motion testing, the Veteran demonstrated "all normal" for flexion to 140 degrees and extension to 0 degrees for each knee. There was objective evidence of pain on movement, but no additional functional loss due to pain, weakness, or lack of endurance. Joint testing was performed with normal findings for each knee. The VA physician indicated no findings of recurrent subluxation, no history of lateral instability, and no history of recurrent effusion. The Veteran denied symptoms of locking, instability, or any episodes of dislocation or subluxation, but reported swelling, interference with standing. The Veteran also retained normal muscle strength. See Knee and Lower Leg Conditions DBQ dated October 2016. In compliance with the Board's April 2019 remand, the Veteran was afforded another VA examination in November 2019, conducted by a VA staff physician. The Veteran again demonstrated "all normal" range of motion with flexion to 140 degrees and extension to 0 degrees. The VA physician noted evidence of pain on movement but indicated that pain does not result in or cause functional loss. Joint testing was performed with normal findings with no history of recurrent subluxation or lateral instability. The physician noted report of swelling with increased sitting but found "no effusion on the current exam". See Knee and Lower Leg Conditions DBQ dated November 2019. The same examiner who conducted the November 2019 provided a clarification opinion in July 2020 indicating that "there is no instability with either knee." See Addendum/Clarification DBQ dated July 2020. Upon review of the evidence of record, the Board finds that the weight of the evidence is against the finding for a higher rating under Diagnostic Code 5260 or Diagnostic Code 5261. For the entire rating period on appeal, the Veteran had all normal range of motion with flexion to 140 and extension to 0 degrees (full extension), including after consideration of functional loss due to pain. At no point has the Veteran been found to have limitation of flexion of the knee to 30 degrees, as required for the next higher 20 percent rating under Diagnostic Code 5260. Further, as the Veteran has not shown limitation of extension of the knees, a separate rating under Diagnostic Code 5261 is also not supported. Therefore, the Board finds that the Veteran is adequately compensated by the assigned initial 10 percent evaluations for left and right knee and higher ratings under Diagnostic Code 5260 or Diagnostic Code 5261 are not warranted. The Board has considered whether a higher disability rating is warranted under 38 C.F.R. § 4.40 for functional loss due to pain, and under 38 C.F.R. § 4.45 for functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint. DeLuca v. Brown, 8 Vet. App. 202 (1995). Here, the Board does not doubt that the Veteran's knee disability causes symptoms of pain and increased pain with prolonged walking or sitting. However, even accounting for additional functional limitation due to such reports of pain, the VA examination reports summarized above reflect that the knee disability has not been shown to produce additional impairment of flexion or extension due to pain or functional loss that would warrant a rating higher. Moreover, the VA examiners (an orthopaedic surgeon and a physician) in October 2016 and November 2019 considered these symptoms in their assessments of the overall severity of the bilateral knee disability. Further, the Veteran's subjective complaints are contemplated in the 10 percent rating presently assigned under Diagnostic Code 5260 for each knee. The Veteran's reports do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation. For these reasons, the Board finds that the preponderance of the evidence is against the Veteran's appeal for an initial rating in excess of 10 percent for left knee and right knee patellofemoral pain syndrome disabilities. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Accordingly, the claims must be denied. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 5. Entitlement to service connection for left and right foot disability. The Veteran contends his left and right foot pain which has gradually increased since exiting service is related to "wear and tear, routine combat arms related activity" in service. See Statements in Support of Claim (VA Form 21-4138) dated November 2017. At the outset, while the Board acknowledges that the Veteran has qualifying service in the Southwest Asia theater of operations (Iraq) and is therefore considered to be a Persian Gulf War Veteran, the record shows that service connection based on the presumption under 38 C.F.R. § 3.317 is not warranted. To specifically address this contention, the Veteran was afforded a Gulf War General Medical Examination in October 2019. After review of the claims file and personal examination of the Veteran, the VA physician found no signs or symptoms that would represent an undiagnosed illness, or any medically unexplained chronic multi-symptom illness recognized by VA as related to Persian Gulf service. The examiner also indicated no current diagnosis of any foot disability. See Gulf War General Medical Examination dated October 2019. Additionally, in compliance with the Board's April 2019 remand, the Veteran was afforded another VA examination in November 2019, which the Board finds the most probative medical evidence of record. After examination of the Veteran, the November 2019 VA physician indicated "no diagnosis for both feet." The physician added that "service treatment records do not reflect ongoing treatment of the foot condition" and there is "insufficient evidence of ongoing treatment for a foot condition." See Medical Opinion of November 2019. Notably, the physician indicated no evidence of pain for the right and left foot and "no functional loss" for right or left lower extremity attributable to claimed condition. See Foot Conditions Disability Benefits Questionnaire (DBQ) dated November 2019. Upon review of the evidence, the Board finds the weight of the evidence is against the finding of a present disability for which entitlement for service connection can be established. In so finding, the Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, the evidence does not indicate a current diagnosis of a left or right foot disability at any point during the course of this appeal. The Veteran's service treatment records and post-service medical records are absent for any treatment or diagnosis of the claimed foot disability. Furthermore, the Board has considered the recent holding in Saunders v. Wilkie in which service connection was deemed possible in the absence of a diagnosis when such factors as pain are shown to limit functional ability. Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018) ("pain alone can serve as a functional impairment and therefore qualify as a disability"). That Federal Circuit decision qualified that holding, however: "[w]e do not hold that a veteran could demonstrate service connection simply by asserting subjective pain. To establish the presence of a disability, the veteran will need to show that [his] pain reaches the level of functional impairment of earning capacity." Id. at 1365. In the present case, the November 2019 VA examiner found no evidence of pain for either foot. Even with consideration of subjective report of foot pain, the evidence does not show that the Veteran experiences any functional limitation or functional impairment of earning capacity due to his claimed foot pain. In fact, a separate VA examination in October 2019 shows that the Veteran maintained fulltime employment since separation and is currently employed as an engineer/technician for satellite communications for military vessels. See Muscle Injuries DBQ dated October 2019. Thus, the Veteran's claimed disability does not amount to functional impairment of earning capacity and Saunders is not applicable here. To the extent that the Veteran claims he has a chronic disability related to service, his lay assertions are not considered competent medical evidence. Although he is certainly capable of describing the history in this case and competent to report symptoms which are within the realm of his personal experience, he is not competent to render a medical diagnosis of a present disability, as this requires medical expertise. Davidson v. Shinseki, 581 F.3d 1313 (2009). For this purpose, the Board assigns more weight to the competent medical evidence, such as the November 2019 VA physician's opinion. Furthermore, the Veteran has not submitted any evidence to the contrary. Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection of left and right foot disability. Accordingly, the claims must be denied. 6. Entitlement to service connection for gastrointestinal disability. 7. Entitlement to service connection for pain in the right side. In June 2016, the Veteran filed his claims for "eosinophilic esophagitis airborne hazards" and "pain in right side when sitting too long", which were denied by rating action of September 2016. The Veteran has not advanced any specific contention regarding his claims other than his general notice of disagreement. See Notice of Disagreement received March 2017. After a thorough review of the record, the Board finds that service connection is not warranted. Similar to the discussion above, the Board finds the weight of the evidence is against the finding of a present disability for which entitlement for service connection can be established. Here, the evidence does not indicate a current diagnosis of a gastrointestinal disability or disability of pain in the right side at any point during the course of this appeal. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). An October 2019 examiner specifically indicated that the Veteran does not currently have an undiagnosed illness or any medically unexplained chronic multi-symptom illness recognized by VA as related to Persian Gulf service, and service connection based on the presumption is not warranted in this case. See 38 C.F.R. § 3.317; see also Gulf War General Medical Examination dated October 2019. Additionally, in compliance with the Board's April 2019 remand, the Veteran was afforded VA examinations in October 2019 for the claimed gastrointestinal disability and pain in the right side which was conducted by the same VA physician. Citing thorough review of the electronic claims file and physical examination of the Veteran, the VA physician indicated, the "veteran's gastrointestinal disability is less likely than not, incurred in active service. He has not been diagnosed with a gastrointestinal disability, nor is there objective evidence of the symptoms he reports." A similar opinion was rendered for the claimed muscle injury, the examiner added, "the veteran's pain in the right side is less likely than not incurred in active service. He has not been diagnosed with a disability, nor is there objective evidence of the symptoms he reports." See Medical Opinion DBQ; Esophageal Conditions DBQ and Muscle Injuries DBQ dated October 2019. Lastly, to the extent that the Veteran claims he has a current disability, his lay assertions are not considered competent medical evidence. Although he is certainly capable of describing the history in this case and competent to report symptoms which are within the realm of personal experience, he is not competent to render a medical diagnosis of a disability, as this requires medical expertise. Davidson v. Shinseki, 581 F.3d 1313 (2009). As such, his lay assertions are insufficient to provide the requisite medical diagnosis. For this purpose, the Veteran's statements, standing alone, have little probative value, and the Board assigns more weight to the objective medical evidence of record. Furthermore, the Veteran has not submitted any evidence to the contrary. After weighing all the evidence, the objective medical evidence of record stands uncontradicted by any other evidence found in the record and is probative in determining whether the Veteran has substantiated his claim for service connection. Thus, the Board finds that the record is absent for a current disability for which entitlement for service connection can be established, and service connection for gastrointestinal disability and disability manifested by pain in the right side is therefore not warranted. Accordingly, the claims must be denied. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A., 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.