Citation Nr: 21064765 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 16-05 079 DATE: October 21, 2021 ORDER The claim for an increased initial rating higher than 40 percent for lumbar myositis is denied. The claim for an initial rating higher than 10 percent for a left hip sprain with impairment of the thigh is denied. The claim for an initial compensable rating for a left hip sprain with limitation of extension is denied. The claim for an initial compensable rating for a left hip sprain with limitation of flexion is denied. The claim for service connection for a right hip disability, to include as secondary to service-connected disability is denied. The claim for service connection for a right knee disability, to include as secondary to service-connected disability is remanded. The claim for service connection for a left knee disability, to include as secondary to service-connected disability is remanded. The claim for service connection for a right foot disability, to include as secondary to service-connected disability is denied. The claim for service connection for a left foot disability, to include as secondary to service-connected disability is denied. The claim for service connection for a bilateral hearing loss disability is denied. REMANDED The claim for service connection for a right ankle disability, to include as secondary to service-connected disability is remanded. The claim for service connection for a left ankle disability, to include as secondary to service-connected disability is remanded. The claim for service connection for hypertension, to include as secondary to service-connected disability is remanded. The claim for service connection for a cardiac disability, to include dyslipidemia is remanded. The claim for a total disability rating due to individual unemployability resulting from service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's lumbar spine myositis most nearly approximates painful and limited motion without ankylosis or intervertebral disc syndrome with no neurological impairment. 2. The Veteran's left hip sprain with impairment of the thigh manifests limitation of motion with abduction greater than 10 degrees without ankylosis, a flail joint, or impairment of the femur. 3. The Veteran's left hip sprain manifests noncompensable limitation of extension to 10 degrees and noncompensable limitation of flexion to 50 degrees. 4. A chronic right hip disability was not incurred during military service, is not etiologically related to an in-service disease or injury, and is not caused or aggravated by a service-connected disability. 5. A chronic right knee disability was not incurred during military service, is not etiologically related to an in-service disease or injury, and is not caused or aggravated by a service-connected disability. 6. A chronic left knee disability was not incurred during military service, is not etiologically related to an in-service disease or injury, and is not caused or aggravated by a service-connected disability. 7. A chronic right foot disability was not incurred during military service, is not etiologically related to an in-service disease or injury, and is not caused or aggravated by a service-connected disability. 8. A chronic left foot disability was not incurred during military service, is not etiologically related to an in-service disease or injury, and is not caused or aggravated by a service-connected disability. 9. The Veteran's bilateral hearing loss disability was not incurred during military service and is not etiologically related to an in-service disease or injury. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 40 percent for lumbar myositis are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.45, 4.71a, Diagnostic Codes 5010, 5235-5243. 2. The criteria for an initial rating higher than 10 percent for a left hip strain with impairment of the thigh are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Codes 5250, 5253, 5254, 5255. 3. The criteria for an initial compensable rating for a left hip strain with limitation of extension are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code 5251. 4. The criteria for an initial compensable rating for a left hip strain with limitation of flexion are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code 5252. 5. The criteria for service connection for a right hip disability are not met. 38 U.S.C. §§ 1131, 1137; 1154; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 6. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 1131, 1137, 1154; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 7. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 1131, 1137, 1154; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 8. The criteria for service connection for a right foot disability are not met. 38 U.S.C. §§ 1131, 1137, 1154; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 9. The criteria for service connection for a left foot disability are not met. 38 U.S.C. §§ 1131, 1137, 1154; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 10. The criteria for service connection for a bilateral hearing loss disability are not met. 38 U.S.C. §§ 1131, 1137, 1154; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1980 to January 1989. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in October 2018 when it was remanded for additional development. It has now returned to the Board for further appellate action. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations at any point during the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). For disabilities evaluated based on limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. DeLuca v. Brown, 8 Vet. App. 202 (1995); Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59; see also Chavis v. McDonough, 34 Vet. App. 1 (2021) (ankylosis may be met by evidence demonstrating the functional equivalent of ankylosis). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. 1. Entitlement to an initial rating higher than 40 percent for lumbar myositis. Service connection for lumbar myositis was granted in the February 2015 rating decision on appeal with an initial 20 percent evaluation assigned effective August 6, 2014. In an April 2021 rating decision, an increased evaluation of 40 percent was granted for the lumbar myositis, also effective August 6, 2014. The service-connected low back disability is therefore rated as 40 percent disabling throughout the initial claims period. The Veteran contends that a higher rating is warranted as his low back disability is productive of severe functional impairment. The Veteran's lumbar myositis is currently rated as 40 percent disabling under Diagnostic Code 5010-5237 and the general rating formula for rating diseases and injuries of the spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. In this case, the Veteran's lumbar myositis is an unlisted disability, and is rated by analogy to arthritis and a lumbosacral strain. 38 C.F.R. § 4.20 (an unlisted disability is rated under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology, are closely analogous). The general rating formula for rating diseases and injuries of the spine was not changed by the February 2021 regulatory changes. Under the general rating formula, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings apply. A 40 percent evaluation is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Id. Thus, to warrant an increased evaluation under the general rating formula, the Veteran's low back disability must demonstrate symptoms which more nearly approximate unfavorable ankylosis of the entire thoracolumbar spine. An initial rating higher than 40 percent is not warranted in this case as the evidence does not establish the Veteran's lumbar myositis most nearly approximates ankylosis of the thoracolumbar spine. Generally, ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). An ankylosed joint is more commonly referred to as "frozen." See, e.g., Dorland's Illustrated Medical Dictionary 286 (32d ed.2012). In this case, the Veteran has retained at least some useful motion of his back throughout the claims period. The February 2015 and November 2020 VA examiners both noted the presence of spinal motion and found that the thoracolumbar spine was not ankylosed. At the most recent VA examination in November 2020, the Veteran was able to forward flex his back to 30 degrees and demonstrated a combined range of motion to 65 degrees with consideration of functional factors such as pain. VA and private treatment records dated throughout the relevant period similarly establish the presence of painful, but not absent, spinal motion. Thus, although the Veteran clearly experiences a demonstrable loss of spinal motion, the medical evidence establishes that he has retained some ability to move and bend his spine throughout the claims period and it is not ankylosed. The competent lay evidence also does not establish ankylosis. Throughout the claims period, the Veteran reported experiencing low back pain that limited his activities. He is competent to report the symptoms he experiences, but the Board finds that the objective medical evidence from the VA examinations and healthcare providers is more probative regarding the range of motion of the service-connected back disability and whether the record establishes actual ankylosis of the spine. The Board also notes that the Veteran has never reported that any part of his spine is frozen, fixated, or immobile. The Board acknowledges the Veteran's lay reports of symptoms including functional loss due to pain during flare-ups and with repetitive use over time. Here, the current 40 percent rating already compensates him for functional loss resulting in forward flexion of the thoracolumbar spine limited to 30 degrees or less with consideration of various functional factors. The Board finds that the preponderance of the evidence is against a finding that the Veteran has functional immobility or ankylosis of his thoracolumbar spine even with consideration of all relevant functional factors. See Chavis v. McDonough, 34 Vet. App. 1 (2021). The Board has also considered whether a rating higher than 40 percent is warranted under the formula for rating intervertebral disc syndrome. The pre-February 2021 version of Diagnostic Code 5243 provides that intervertebral disc syndrome is rated either under the general rating formula or the formula for rating intervertebral disc syndrome based on incapacitating episodes, whichever method results in a higher evaluation. Under the current version of Diagnostic Code 5243, this code is only assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root. Diagnostic Code 5242 is assigned for all other diagnoses. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2020 & 2021). In this case, the competent medical evidence establishes that the Veteran's service-connected disability does not include intervertebral disc syndrome. As such, Diagnostic Code 5243 (either the former or current version) is not for application. Similarly, the Board has considered whether separate ratings are warranted for any neurological impairment associated with the service-connected lumbar spine disability. The criteria for rating the spine provide that associated neurologic abnormalities, to include radiculopathy of the lower extremities, and/or bladder or bowel impairment, are rated separately under the appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). The Veteran's neurological systems were normal at the February 2015 and November 2020 VA examinations and the Veteran has not reported any neurological symptoms or impairment associated with the service-connected lumbar disability. A July 2014 report from a private physician notes the Veteran's complaints of radiating stiffness, numbness, tingling, sensory loss, cramps, and weakness from the low back, but the report does not contain any reference to physical examination findings or a diagnosis of radiculopathy or similar neurological condition. The Board also notes that treatment records from the VAMC and the Veteran's other private doctors are completely negative for neurological complaints associated with the Veteran's service-connected disability. The Board finds that the July 2014 private doctor's statements are outweighed by the other evidence of record, including the findings of the February 2015 and November 2020 VA examiners who performed orthopedic and neurological examinations. Therefore, separate ratings are not warranted as the Veteran does not manifest any neurological impairment associated with the service-connected lumbar myositis. The Veteran's lumbar spine myositis is therefore appropriately rated as 40 percent disabling throughout the initial claims period and the claim for an increased rating is denied. 2. Entitlement to an initial rating higher than 10 percent for a left hip sprain with impairment of the thigh. 3. Entitlement to an initial compensable rating for a left hip sprain with limitation of extension. 4. Entitlement to an initial compensable rating for a left hip sprain with limitation of flexion. Service connection for a left hip strain was awarded in the February 2015 rating decision on appeal effective August 6, 2014. The Veteran's left hip strain was awarded three separate evaluations: a 10 percent evaluation for impairment of the thigh, a noncompensable evaluation for limitation of extension, and a noncompensable evaluation for limitation of flexion. The Veteran contends that higher initial ratings are warranted to adequately compensate his symptoms of pain and functional impairment. As a preliminary matter, the Board notes that the Veteran has never manifested ankylosis of the left hip and none of the medical evidence (including X-rays and VA and private examination findings) demonstrates the presence of ankylosis. VA examiners in February 2015 and November 2020 both specifically found that the Veteran's left hip was not ankylosed, and the Veteran does not contend that he has lost all useful motion of his left. Similarly, there is also no evidence of a flail joint of the hip or impairment of the femur with any nonunion, malunion, or fracture. Rather, the Veteran contends that his pain and limited motion results in functional impairment that most nearly approximates the criteria associated with higher disability evaluations. The Board therefore finds that Diagnostic Codes 5250, 5254, and 5255, pertaining to hip ankylosis, a flail joint, and impairment of the femur are not for application in this case and will now turn to the rating criteria pertaining to limitation of motion. The former and current versions of the criteria pertaining to rating the hip are identical. Normal ranges of motion of the hip are for hip flexion from 0 degrees to 125 degrees and hip abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. Limitation of motion of the hip or thigh may be rated under Diagnostic Code 5250 (ankylosis of the hip), Diagnostic Code 5251 (limitation of extension), 5252 (limitation of flexion), or Diagnostic Code 5253 (impairment of the thigh). The Board will first address the Veteran's current 10 percent rating based on impairment of the thigh and Diagnostic Code 5253. Under Diagnostic Code 5253, impairment of the thigh may be rated based on limitation of abduction, limitation of adduction, or limitation of rotation. A 10 percent rating will be assigned for limitation of rotation where the individual cannot toe-out more than 15 degrees on the affected leg, or for limitation of adduction where the individual cannot cross the legs. A 20 percent rating will be assigned for limitation of abduction where there is motion lost beyond 10 degrees. Id. The Veteran is currently in receipt of the maximum rating based on limitation of rotation and adduction under Diagnostic Code 5253. A higher rating of 20 percent is only possible if abduction is lost beyond 10 degrees. In this case, abduction was most limited at the February 2015 VA examination when it was measured to 20 degrees. This finding was based on the Veteran's range of motion after repetitive testing and with consideration of functional factors. The Veteran therefore retains more abduction than contemplated by a maximum 20 percent evaluation under Diagnostic Code 5253 and higher initial rating based on impairment of the thigh is not warranted. The Veteran's left hip strain is also assigned a separate noncompensable rating for impairment to extension under Diagnostic Code 5251. This diagnostic code provides a 10 percent disability rating for limitation of extension of the thigh that is limited to 5 degrees. 38 C.F.R. § 4.71a. Extension of the thigh was most limited at the February 2015 rating decision when it was measured to 10 degrees. This measurement was made with consideration of functional factors such as complaints of pain, repetitive motion, and based on the Veteran's reports. Thus, the limitation of thigh extension manifested by the Veteran throughout the claims period is noncompensable under Diagnostic Code 5251 and a higher rating is not possible based on limitation of extension. Finally, the Veteran's impairment to flexion is currently rated as noncompensably disabling in recognition of the Veteran's loss of flexion that nonetheless does not most nearly approximate a 10 percent evaluation under Diagnostic Code 5252. Flexion was most limited during the claims period at the November 2020 VA examination when it was measured to 50 degrees. The Veteran did not manifest any additional loss of flexion with repetitive testing, and while pain was reported on testing, the examiner found it did not result or cause any functional loss. Thus, the Veteran manifests flexion of the left hip to 50 degrees, even with consideration of functional factors. This level of impairment is not compensable under Diagnostic Code 5252. In sum, the Veteran's left hip strain is properly rated as 10 percent disabling for impairment of the thigh and limitation of abduction under Diagnostic Code 5253, noncompensably disabling for limitation of extension under Diagnostic Code 5251, and noncompensably disabling for limitation of flexion under Diagnostic Code 5252 throughout the initial claims period. The Board has considered whether there is any other schedular basis for granting a higher rating, but has found none. The Board has also considered the statements of the Veteran. The Veteran has described experiencing pain of the left hip and limitation of motion that impairs his ability to sit, stand, walk and climb stairs. The type of impairment reported by the Veteran is contemplated by the three separate ratings assigned his left hip disability, to include pain and limitation of motion of the hip in various directions. In determining the appropriate ratings for the left hip disability, the Board has also considered functional factors such as those reported by the February 2015 and November 2020 VA examiners, to include impairment associated with repetitive motion and flare-ups of symptoms. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claims for any additional increased ratings. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection is also provided for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). 5. Entitlement to service connection for a right hip disability, to include as secondary to service-connected disability. 6. Entitlement to service connection for a right knee disability, to include as secondary to service-connected disability. 7. Entitlement to service connection for a left knee disability, to include as secondary to service-connected disability. 8. Entitlement to service connection for a right foot disability, to include as secondary to service-connected disability. 9. Entitlement to service connection for a left foot disability, to include as secondary to service-connected disability. The Veteran contends that service connection is warranted for disabilities of the right hip, bilateral knees, and bilateral feet as they were incurred due to active duty service. In the alternative, the Veteran contends that his disabilities are caused or aggravated by service-connected lumbar and/or left hip disabilities. The Board will first address the Veteran's contentions regarding direct service connection before turning to whether service connection is warranted on a secondary basis. The Board concludes that while the Veteran has the current disabilities claimed and an in-service injury, the preponderance of the evidence weighs against finding that the Veteran's right hip, knee, and foot disabilities began during service or are otherwise related to an in-service injury, event, or disease. The first element of service connectiona current disabilityis present. VA examinations in February 2015 and November 2020 include diagnoses of right hip myositis, bilateral osteoarthritis of the knees with tendinosis, bilateral patellofemoral syndrome of the knees, and bilateral plantar fasciitis of the feet. VA treatment records also document findings of bilateral knee arthritis and bilateral plantar fasciitis. The Veteran has also consistently complained of pain and stiffness in all the relevant joints limiting his ability to walk and stand. He is competent to describe the symptoms he experiences, and the Board finds that his reports are credible. Current disabilities are therefore demonstrated by the competent medical and lay evidence. The Board also finds that in-service injuries are present. Service records are negative for treatment or complaints pertaining to the claimed disabilities and the Veteran has not provided any specific statements in support of his claims describing his injuries or activities during service. Although the medical or lay evidence does not establish the presence of specific injuries, the Board will resolve any doubt in the Veteran's favor and finds that the nature of his service is consistent with the incurrence of some injury to the claimed joints. Service personnel records establish that the Veteran served as a hospital corpsman and a field medical service technician. There is also a notation that the Veteran served aboard the USS PENSACOLA in support of a multinational peacekeeping mission in Beirut, Lebanon from February 1983 to May 1983. In its October 2018 decision, the Board found that the Veteran was exposed to combat stressors and the Board finds that circumstances and type of the Veteran's service is consistent with injuries to the hip, knees, and feet. See 38 U.S.C. § 1154(b) (If the Veteran engaged in combat with the enemy, and it is claimed that a disease or injury was incurred in such combat, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service.); see also Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012) (Even where the combat presumption applies, a veteran must still show that a causal relationship exists between the present disability and the in-service injury or disease.). Although current disabilities and in-service injuries are present, the preponderance of the evidence weighs against a conclusion that the Veteran's disabilities began during service or are otherwise related to in-service injuries. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service and post-service treatment records weigh against the claims for service connection. As noted above, service records are negative for any evidence of the claimed disabilities with no complaints or treatment pertaining to the right hip, knees, or feet. Post-service medical records, while documenting treatment for disabilities of the knees and feet, do not contain any evidence of the claimed conditions until February 2015, more than 25 years after service, when the Veteran's private physician included a diagnosis of plantar fascial fibromatosis on the Veteran's problem list. The first post-service complaint of right hip or knee problems dates from May 2015, when the Veteran filed for benefits from the Social Security Administration (SSA). Furthermore, records from the VA Medical Center (VAMC) first reference complaints of knee pain in April 2016. The Veteran dated the onset of his knee pain to approximately 2015 during a May 2018 VA physical medicine and rehabilitation consultation. The absence of any clinical evidence of the claimed disabilities until decades after service weighs the evidence against a finding that the Veteran's conditions were present in service, particularly as the Veteran has not specifically alleged the onset of the conditions during service or for many years thereafter. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000); see also Horn v. Shinseki, 25 Vet. App. 231, 239 (2012). Service connection is also possible for certain disabilities, to include arthritis, on a presumptive basis as a chronic disease in accordance with 38 C.F.R. §§ 3.307 and 3.309. The July 2014 private physician diagnosed arthritis of the hips, knees, and feet (despite any indication a physical examination or X-rays were conducted). However, as the medical and lay evidence clearly establishes the Veteran's conditions had their onset many years after service, service connection is not warranted on a presumptive basis for the claimed conditions. See 38 C.F.R. §§ 3.307 and 3.309 (For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service). The weight of the other competent evidence is also against a finding that the Veteran's claimed disabilities are related to his in-service injuries. The record contains conflicting medical opinions regarding the etiology of the disabilities on appeal, but the Board finds that the VA opinions weighing against service connection are more probative than the positive medical opinion provided by the Veteran's private physician. In support of his claim, the Veteran submitted a letter from a private physician in July 2014 linking arthritis of the hips, knees, and feet to military service. However, the Board finds that the medical opinion provided by the Veteran's private doctor is not probative. The private physician found that the Veteran's disabilities were all due to military service; however, these statements were unaccompanied by any rationale. The private doctor merely provided a generalized statement that the Veteran's disabilities were "secondary to military service performance." No mention was made of how the claimed disabilities were due to service, the absence of any evidence in the service records, or the absence of any evidence in the post-service records until many years after discharge. The lack of an accompanying rationale renders the July 2014 private medical opinion of no probative value. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). In contrast, the Board finds that the medical opinion reports of the November 2020 VA examiners are probative evidence weighing against service connection. The VA examiners provided medical opinions against service connectionfinding that the Veteran's right hip, bilateral knee, and bilateral foot disabilities were not etiologically related to any incident of active service. The examiners noted that the Veteran's service records were negative for complaints or treatment of the claimed disabilities, and the Veteran himself reported that the conditions began decades after his separation from active duty without any reported link to service. The examiners also considered the findings of the July 2014 private physician, but noted in August 2021 addendum opinions that the private doctor's report was unaccompanied by any explanatory rationale and was not based on any actual physical examination or imaging reports. The Board finds that the November 2020 medical opinions are probative as they are based on an accurate medical history and include explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Therefore, the VA medical opinions clearly outweigh the July 2014 opinion of the private physician. The Board has also considered the Veteran's lay statements. As noted above, the Veteran contends that service connection is warranted in this case, but has not provided any specific statements regarding how his current disabilities are connected to active duty. The Veteran is competent to describe his symptoms, and he has consistently reported that his symptoms began decades after his separation from military service. In any event, the Veteran is not competent to provide an opinion regarding the etiology of his disabilities. Determining the etiology of his right hip, bilateral knee, and bilateral foot conditions is a medically complex question, requiring knowledge of various anatomical relationships and interpretation of diagnostic medical testing, such as X-rays. Therefore, it is outside the competence of the Veteran as the record does not include any indication that he possesses the medical training or credentials to make such determinations. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the medical evidence of record. Furthermore, the Board notes that the Veteran has not reported a history of continuing symptoms since service. See 38 C.F.R. § 3.303(a) and (d); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The history he has provided is to the effect that he served on active duty, incurred some unspecified injuries, and developed the claimed disabilities many years later. The Veteran has not reported a history of continuous symptoms since service and his lay contentions regarding service connection are outweighed by the competent medical evidence of record. The Board therefore finds that service connection is not warranted for right hip, knee, and foot disabilities as directly due to active duty. The Board will now turn to the Veteran's contentions regarding secondary service connection. The Veteran contends that his right hip, knee, and foot disabilities were caused or aggravated by his service-connected lumbar spine and/or left hip disabilities. The only medical evidence of record addressing secondary service connection are the medical opinions of the VA examiners in November 2020 and April 2021, and these opinions weigh against the claims. After physically examining the Veteran and reviewing the claims file, the examiners determined that the right hip, knee, and foot disabilities were not caused or aggravated by the service-connected lumbar and left hip conditions. The examiners opinions were based on the nature of the Veteran's diagnosed conditionsmyositis, arthritis, patellofemoral syndrome, and plantar fasciitiswhich develop separately from the Veteran's lumbar and left hip conditions and involve anatomically independent sites. Additionally, the examiners noted that the Veteran had no gait alterations due to his service-connected conditions that could cause or aggravate disabilities of the claimed joints. Finally, review of the relevant medical literature did not indicate any method for linking the claimed right hip, bilateral knee, and bilateral foot conditions to the Veteran's lumbar myositis or left hip strain. The November 2020 and April 2021 VA medical opinions were accompanied by a full rationale and are based on the accurate facts of the case. Therefore, they are probative competent evidence against secondary service connection. Nieves-Rodriguez at 304. Again, the Board has considered the Veteran's statements in support of his claim, but finds that his lay statements are outweighed by the competent medical evidence against the claim. The Veteran has not provided any specific statements in support of secondary service connection, though VAMC records do include a notation in July 2018 that his right knee pain began to worsen a year earlier after a hip rotation injury. At the VA physical therapy assessment documenting these statements, the Veteran also presented with an antalgic gait pattern. However, the Veteran did not specify which hip had affected the right knee, nor do post-service treatment records include any other instances of gait abnormalities. As such, the Board finds that the Veteran's lay statements are outweighed by the probative medical evidence weighing against secondary service connection and reiterates that the Veteran is not competent to render an opinion regarding the etiology of his disabilities. Jandreau at 1377. The competent evidence of record is therefore against a nexus between the Veteran's right hip, bilateral knee, and bilateral foot disabilities and active duty service. Furthermore, the evidence is against service connection for the claimed disabilities on a secondary basis. Accordingly, the Board must conclude that the preponderance of the evidence is against the claims and they are denied. 38 U.S.C. § 5107(b). 10. Entitlement to service connection for a bilateral hearing loss disability. The Veteran contends that service connection is warranted for bilateral hearing loss as it was incurred due to noise exposure during active military service. As an initial matter, the Board finds that the record establishes the presence of a current bilateral hearing loss disability for VA purposes in accordance with 38 C.F.R. § 3.385. Bilateral sensorineural hearing loss to the degree required by VA was demonstrated at a VA audiological examination in April 2021. Thus, the first element of service connection is established. The Board also finds that an in-service injury is present. As noted above, the Board has found the Veteran participated in combat and some noise exposure is consistent with this service. The Veteran also reported during the April 2021 VA examination that he was exposed to noise during service through firearms, explosions, and aircraft. The Veteran is competent to report noise exposure during service and the Board finds his statements are credible. The Board therefore finds that the second element of service connection is demonstrated. Regarding the third element of service connection, a nexus between the Veteran's hearing loss and in-service injury/noise exposure, service records do not indicate such a link. Available service treatment records are entirely negative for complaints or treatment related to the Veteran's hearing. Although the Veteran's enlistment and separation examinations are not of record, audiograms performed in October 1981, September 1983, and January 1984 are included in the service records. These audiograms document some worsening of the Veteran's hearing from 1981 to 1983, but also show consistently normal hearing for VA purposes. Thus, service records do not establish a hearing loss disability was present during the Veteran's active military service. Additionally, the record does not contain any medical evidence of an audiological defect until many years after service. The earliest evidence of post-service hearing loss dates from July 2014, more than 25 years after discharge, when the Veteran's private physician noted the Veteran's complaints of hearing loss. Hearing loss was also reported at a February 2015 VA examination, though audiological testing at that time did not demonstrate hearing loss of sufficient severity to constitute a VA disability in accordance with 38 C.F.R. § 3.385. A bilateral hearing loss disability was not diagnosed until April 2021, during a second VA audiological examination. Based on the above, the Board cannot find that an audiological disability manifested to a compensable degree within a year following the Veteran's separation from active duty. As such, service connection is not warranted on a presumptive basis in accordance with 38 C.F.R. §§ 3.307 and 3.309. The weight of the competent medical evidence is also against the claim. Although the Veteran's private physician provided a medical opinion in support of service connection for hearing loss in July 2014, as discussed in detail above, the Board has determined that this opinion is of no probative value as it is unaccompanied by any rationale, does not indicate review of the Veteran's service or post-service records, and is not based on examination results. Conversely, the record contains two medical opinions from a VA audiologist weighing against the claim. These opinions, dated in April 2021 with an August 2021 addendum, were rendered following audiological testing and review of the claims file with consideration of the Veteran's own reported history. The VA examiner concluded that while the Veteran had some noise exposure during service, the nature and pattern of his hearing loss was not strongly characteristic of damage due to hazardous noise exposure. The examiner further noted that while service records documented a "significant shift" in the Veteran's high frequency hearing between the 1981 and 1984 audiograms, his hearing was measured as normal in both ears at all audiograms until April 2021. The VA medical opinions are accompanied by a well-explained rationale and reference specific evidence in the service and post-service record. They are therefore probative and clearly outweigh the July 2014 private medical opinion. Service connection is also possible for certain chronic disabilities under 38 C.F.R. § 3.303(b) based on a continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Hearing loss is considered a chronic disease under 38 C.F.R. §§ 3.307 and 3.309 (as an organic disease of the nervous system). The Veteran has reported the onset of hearing loss during service and the Board interprets this statement as reporting a continuity of symptoms since service. During the April 2021 VA examination, the Veteran reported that he first noticed some difficulty in hearing people speak in 1988, while he was still serving on active duty. The Veteran is competent to report when he noticed symptoms of hearing loss, but the Board finds his statements are outweighed by the competent medical evidence of record. First, the Board notes that while the Veteran stated his hearing difficulties began during active duty, he did not manifest a hearing loss disability on audiograms performed in 1981, 1983, and 1984. Additionally, the Veteran stated during a February 2015 VA examination that he was not exposed to loud noises during service after 1984. Second, a hearing loss disability is not documented until April 2021even at the February 2015 VA examination the Veteran manifested normal hearing. Finally, the Board notes that the Veteran's statements regarding the onset of his hearing loss recall events that occurred more than 30 years prior. Thus, while the Veteran has reported experiencing some degree of hearing loss since service, the Board finds that his lay statements and recollections are outweighed by the competent medical evidence of recordevidence which establishes a hearing loss disability was not present until decades after service and the nature of the Veteran's hearing loss is not characteristic of a noise-induced disability. The Board has also considered the Veteran's statements connecting his current hearing loss to service, but as a lay person, he is not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999). The Board acknowledges that the Veteran is competent to report observable symptoms, but finds that his opinion as to the cause of the symptoms simply cannot be accepted as competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1131, 1336 (Fed. Cir. 2006). Therefore, his statements linking his hearing loss to service do not support the claim. In sum, although the first two elements of service connection are present in this case, the evidence weighs against a nexus between the Veteran's hearing loss and service. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim and it is denied. 38 U.S.C. § 5107(b). REASONS FOR REMAND 1. Entitlement to service connection for a right ankle disability, to include as secondary to service-connected disability. 2. Entitlement to service connection for a left ankle disability, to include as secondary to service-connected disability. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected disability. 4. Entitlement to service connection for a cardiac disability, to include dyslipidemia. 5. Entitlement to TDIU. The Board regrets further delay in this case, but finds that a remand is necessary to further develop the remaining claims on appeal. With respect to the claims for service connection for the right and left ankles, the Board finds that medical opinions are necessary to determine the etiology of the Veteran's current disabilities. The Veteran was provided VA examinations of the ankle in February 2015 and November 2020, but the examiners concluded that ankle disabilities were not present. As such, medical opinions addressing the etiology of the claimed ankle conditions were not issued. However, the Board finds that current ankle disabilities are demonstrated by the evidence of record. The Veteran has consistently reported that he experiences ankle pain, stiffness, and a tingling sensation with prolonged standing and walking. The February 2015 VA examiner also noted that range of motion was limited in both ankles. The Veteran is competent to describe the symptoms he experiences and has stated that his claimed ankle conditions limit his ability to stand and ambulate. The Board finds these statements are competent and credible and current ankle disabilities are present based on the evidence of limited motion, pain, and functional impairment. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a "disability" requires some showing of functional impairment). A remand is therefore required to obtain a medical opinion addressing a possible link between the Veteran's ankle disabilities and service or a service-connected disability. Regarding the claims for service connection for hypertension and a cardiac disability, review of the Veteran's VAMC treatment records shows that he reported receiving treatment with a private cardiologist in March 2015. The claims file does not contain medical records from this provider and the claims file does not indicate that attempts have been made to obtain such records. On remand, efforts should be made to obtain any available records from the Veteran's private cardiologist. Finally, the claim for TDIU is remanded as it is inextricably intertwined with the pending claims for service connection. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for his private cardiologist, identified in a March 2015 VAMC record as Dr. Abdala. If an adequate release form is provided by the Veteran, make two requests for the authorized records from the private cardiologist, unless it is clear after the first request that a second request would be futile. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's bilateral ankle disabilities are at least as likely as not related to the Veteran's combat service or caused or aggravated by the service-connected lumbar myositis or left hip strain. The Board has determined that bilateral ankle disabilities are present based on the Veteran's complaints of pain, stiffness, and functional impairment, as well as the February 2015 VA examination findings of limited motion. The Veteran has not provided specific examples of ankle injuries during service, but the record establishes his participation in combat and the Board has therefore recognized some injury to the ankles is consistent with this service. The Veteran also contends that service connection is warranted as secondary to the service-connected lumbar and left hip disabilities. K. Conner Veterans Law Judge Board of Veterans' Appeals M. Riley, Attorney for the Board Department of Veterans Affairs 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.