Citation Nr: 21069531 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 17-23 747 DATE: November 18, 2021 ORDER The application to reopen a previously denied claim of entitlement to service connection for left knee disability is granted. The application to reopen a previously denied claim of entitlement to service connection for right knee disability is granted. The application to reopen a previously denied claim of entitlement to service connection for left foot disability is granted. Entitlement to service connection for left knee disability, secondary to service connected right foot metatarsalgia (right foot disability), on a causation basis, is granted. Entitlement to service connection for right knee disability, secondary to service connected right foot disability, on a causation basis, is granted. Entitlement to service connection for left foot disability, secondary to service connected right foot disability, on a causation basis, is granted. Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to an initial rating higher than 10 percent for service connected right foot metatarsalgia is denied. REMANDED Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. A January 2014 rating decision denied service connection for right knee, left knee, and left foot conditions. The Veteran did not timely file a notice of disagreement to the decision and new and material evidence was not received within the one-year appeal period. 2. Evidence added to the record since the January 2014 decision became final relates to an unestablished fact that is necessary to substantiate the claims of service connection for right knee, left knee, and left foot disability. 3. The evidence is at least evenly balanced as to whether the Veteran's left knee disability was caused by his service connected right foot disability. 4. The evidence is at least evenly balanced as to whether the Veteran's right knee disability was caused by his service connected right foot disability. 5. The evidence is at least evenly balanced as to whether the Veteran's left foot disability was caused by his service connected right foot disability. 6. The evidence is at least evenly balanced as to whether the Veteran's PTSD is related to an in-service stressor. 7. The Veteran is in receipt of the maximum schedular rating available for right foot metatarsalgia, and an additional separate compensable foot disability has not been demonstrated. CONCLUSIONS OF LAW 1. The January 2014 rating decision that denied the Veteran's claim for, among one other thing, entitlement to service connection for right knee, left knee, and left foot conditions is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. As the evidence received since the January 2014 rating decision is new and material, the requirements to reopen the claims for entitlement to service connection for right knee, left knee, and left foot disability have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.102, 3.156. 3. The criteria for service connection for a left knee disability, secondary to service connected right foot disability, on a causation basis, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for a right knee disability, secondary to service connected right foot disability, on a causation basis, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for service connection for a left foot disability, secondary to service connected right foot disability, on a causation basis, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.304 (f). 7. The criteria for an initial rating higher than 10 percent for right foot metatarsalgia have not been met. 38 U.S.C. §§ 1155 ; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.71(a); diagnostic code (DC) 5279. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1982 to December 1985. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which denied service connection for PTSD, continued its denials of service connection for left foot condition, right and left knee conditions, and granted service connection for right foot condition, evaluating it as noncompensable from July 31, 2013. In February 2016, the Veteran filed his notice of disagreement with the noncompensable rating for right foot disability, and the denials of service connection, was issued a statement of the case in April 2017, and in May 2017 perfected his appeal to the Board. In an April 2017 Decision Review Officer Decision, RO granted a rating increase for the Veteran's right foot disability, evaluating it as 10 percent disabling from February 18, 2015 creating a "staged" rating, determined that the previously assigned July 31, 2013 effective date was clear and unmistakable error (CUE), and proposed to change the effective date to February 18, 2015. In a June 2018 rating decision, the RO, finding CUE, changed the effective date for the grant of service connection for right foot disability to February 18, 2015. In July 2021, the Veteran appeared at a virtual Board hearing before the undersigned Veterans Law Judge. A copy of the transcript is of record. NEW AND MATERIAL The AOJ denied the Veteran's claims of entitlement to service connection for, among one other thing, left foot condition, left knee condition, and right knee condition in January 2014, finding no nexus to military service. The Veteran neither appealed this decision nor submitted new and material evidence within the one-year appeal period. The decision is therefore final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A previously denied claim may be reopened by submission of new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New and material evidence cannot be cumulative or 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. When determining whether 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). At the time of the January 2014 rating decision, evidence relevant to the service connection claims included service treatment records from September 1982 to November 1985, a July 2013 statement, and VA treatment records. Evidence received since that prior final denial includes a March 2017 VA examination, a VA Medical opinion from April 2017, July 2021 hearing testimony, and additional statements. This evidence was not previously of record and relates to unestablished facts necessary to substantiate the claims for service connection as it provides evidence regarding the etiology of the Veteran's current disabilities. Thus, the evidence is new and material, and the criteria for reopening the claims for service connection for left foot, left knee, and right knee disabilities have been met. SERVICE CONNECTION Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for disability proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (b). Left Foot, Left Knee, and Right Knee The Veteran testified that he has symptoms of pain and swelling in his left foot which began approximately 3 years prior, and reported that he was told by his podiatrist that he is putting pressure on the left side because he is limping, which is causing his left foot symptoms, and pressure on his knees. The Veteran testified that his podiatrist stated that his knee problems are related to his right foot disability. He stated that he has trouble bending his knees, and that he can only keep them bent for a few minutes. The Veteran reported that if he squats for a long period of time, he has to use knee pads, and also reported trouble with stairs. He stated that on a bad day, it can take up to 3 hours to get out of bed due to "all the arthritis". The Veteran reported in his Form 9 appeal that he has great pain and discomfort in his left foot, and difficulty walking and standing for a long period of time. In his January 2016 statement, the Veteran reported that he has limited motion and mobility in his knees which was caused from walking tenderly on his feet due to his foot disabilities. An April 2017 VA examination report indicates the examiner opined that the Veteran's bilateral knee disabilities are less likely than not (less than a 50 percent probability) proximately due to, or the result of his service connected right foot disability. The examiner stated that there is no clear evidence from orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in major muscle or nerve damage causing partial or complete paralysis; or shortening of the injured limb resulting in length discrepancy of more than 5 cm so that the individual's gait pattern has been altered to the extent that clinically there is an obvious Trendelenburg gait. He concluded that the Veteran's bilateral knee disabilities are due to something intrinsic to the knees and not the right foot. January 2020 post-service treatment records reflect that the Veteran was treated for bilateral knee pain, and indicate that the Veteran reported injuring his left knee while playing high school football. The Board notes that the Veteran reported suffering a left knee injury in high school. However, a Veteran is presumed to have been sound upon entry into active service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). In other words, "[w]hen no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Here, the Veteran's September 1982 medical examination report upon entry is normal, without any notation as to a left knee injury. Additionally, there is no evidence that the Veteran had a left knee injury that was clearly and unmistakably not aggravated by service within his service treatment records or the claims file, thus the Veteran is presumed to have been sound upon entry into active duty service. The evidence of record is at least evenly balanced as to whether the Veteran's left foot, left knee, and right knee disabilities were caused by his service connected right foot disability. The Veteran has competently and credibly stated that he suffers from pain, discomfort, and limited mobility in his left foot and both knees. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). With regard to whether the current disability requirement has been met, the Federal Circuit held that pain alone can constitute disability if it causes impairment in earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). In this case, the evidence shows that the Veteran has bilateral knee pain, and left foot pain that caused impairment in earning capacity, as it impacts his mobility, affecting his ability to perform his duties as a construction worker. Therefore, the current disability requirement for service connection has been met. While the April 2017 examiner opined that the Veteran's bilateral knee injuries are less likely than not due to his service connected right foot disability, the Veteran has testified that his podiatrist has stated that his bilateral knee and left foot problems are related to his service connected right foot disability. In this regard, the Court has held that lay evidence regarding what a medical professional told a lay person was specifically listed as an example of competent lay testimony in Jandreau, 492 F.3d at 1377. Therefore, the Veteran is competent to relate what physicians stated to him regarding a possible nexus. While the Veteran's podiatrist did not provide an extensive rationale to support their opinion, considering the opinion as a whole and in the context of the evidence of record, the podiatrist found that the nature and symptoms of the Veteran's service connected right foot disability made it likely that they had resulted in his current bilateral knee, and left foot disabilities. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). There are therefore conflicting medical opinions, each probative, on the issue of whether the right and left knee disabilities, and left foot disability are caused by his service connected right foot disability. The evidence is therefore evenly balanced on this question. As the reasonable doubt created by the relative equipoise in the evidence of record must be resolved in favor of the Veteran, service connection for right and left knee disabilities, and left foot disability, secondary to service connected right foot disability on a causation basis, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102. PTSD There are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304 (f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires: (1) a medical diagnosis of PTSD utilizing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM 5) criteria, in accordance with 38 C.F.R. § 4.125 (a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See 38 C.F.R. § 3.304 (f). The Board notes that the DSM-IV has been updated with a Fifth Edition (DSM-5). VA has amended 38 C.F.R. § 4.125(a) to require the diagnosis to conform to DSM-5. The amendment applies to cases such as this one that were certified to the Board after to August 4, 2014. See Schedule for Rating DisabilitiesMental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14308 (Mar. 19, 2015). The record contains psychiatric diagnoses other than PTSD. Therefore, the Board has expanded the issue on appeal to include all psychiatric disorders, to include PTSD consistent with the holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran's January 1985 medical history report does not reflect that the Veteran suffers from any psychiatric disabilities, or symptomatology associated with a psychiatric disability, and his January 1985 medical examination report is normal. The Veteran's November 1985 Statement of Intent in his military personnel records indicate that he was stationed in Dubuque, Iowa. A January 2015 disability benefits questionnaire (DBQ) reflects diagnoses of major depressive disorder, panic disorder, and alcohol abuse, with the examining nurse practitioner (NP) noting that the Veteran has not been diagnosed with PTSD. The DBQ indicated that it is possible to differentiate what symptoms are attributable to each diagnosis, and the NP stated that the symptoms may all be related to PTSD. In a June 2015 statement, the Veteran reported suffering trauma while serving in the USCG in Dubuque, Iowa as Aid to Navigation and Search and Research Unit. He stated that he had to recover a number of jumpers from the Julien Dubuque Bridge during the 1980s, and also recovered decapitated remains from a boating accident. He submitted newspaper articles which described boating accidents which resulted in the death of 2 men. In a June 2015 psychology consultation, the Veteran's mental health counselor indicated that his PTSD checklist assessment was positive, and that the Veteran experienced his stressful event while in the Coast Guard. In a December 2015 email, the director of Archival Operations reported that no U.S. Coast Guard records were held at their location for Dubuque, Iowa for the relevant time period. In a January 2016 memorandum, the Joint Services Records Research Center (JSRRC) coordinator notified VA that the Veteran's reported non-combat related stressors could not be verified or conceded based on the information provided by the Veteran. A January 2017 VA psychiatric note reflects a DSM-5 diagnosis for PTSD. The evidence of record, specifically the January 2017 VA psychiatric note, indicates that the Veteran has a current diagnosis of PTSD which meets the diagnostic criteria under DSM-5. The Veteran has provided competent and credible statements that he was part of a recovery mission, fishing dead bodies from water while in service, and provided articles describing the events. Additionally, his service records reflect that he was stationed in Dubuque, Iowa at the time of the recovery missions, providing credible corroborating evidence of the Veteran's in-service stressor. Therefore, the remaining issue is whether the Veteran's psychiatric disability is related to the in-service stressor. 38 C.F.R. § 3.304 (f). Here, the June 2015 mental health counselor has concluded that the Veteran's PTSD symptomatology was due to the described stressful event endured during service. While the counselor did not provide an extensive rationale supporting her conclusion, considering the opinion as a whole and in the context of the evidence of record, the counselor found that the nature and symptoms of the Veteran's PTSD made it likely that it was due to his stressor of recovering bodies while in service. Monzingo, 26 Vet. App. at 106; Acevedo, 25 Vet. App. at 294. There is no other opinion of record regarding the etiology of the Veteran's PTSD. Therefore, the weight of the evidence supports a nexus between the Veteran's diagnosed PTSD and his in-service stressor. As any reasonable doubt must be resolved in favor of the Veteran, entitlement to service connection for PTSD is warranted. 38 U.S.C. §§ 5107 (b); 38 C.F.R. § 3.102. As indicated above, the Veteran has been diagnosed with other psychiatric disorders in addition to PTSD. Notably, while the January 2015 NP initially indicated that it was possible to differentiate what symptoms were attributable to each diagnosis, she was not considering a diagnosis of PTSD, and additionally noted that each symptom may be related to PTSD. As the January 2015 NP indicated that the symptoms of the Veteran's psychiatric disorders may be related to his PTSD, VA will attribute the effects to the now service connected PTSD. See Howell v. Nicholson, 19 Vet. App. 535, 540 (2006); Mittleider v. West, 11 Vet. App. 181, 182 (1998) (VA must apply the benefit of the doubt doctrine and attribute the inseparable effects of a disability to the claimant's service-connected disability). Consideration of the issue of service connection for a psychiatric disorder other than PTSD is, therefore, unnecessary. RATINGS Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are 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. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination, or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). When evaluating a disability under VA's General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), the criteria for a rating based on ankylosis may be met by evidence demonstrating the functional equivalent of ankylosis, i.e., functional loss consistent with that contemplated by ankylosis. See Chavis v. McDonough, No. 18-2928 (Vet. App. Apr. 16, 2021). Right Foot Disability The Veteran testified that his right foot disability began in service during boot camp, stating the boots "messed up" his feet, reporting swelling under his big toe to the point that he could not walk on the foot or put on a shoe. He stated that over the course of years, he has been walking on and putting more pressure on his left side which causes other problems with his knees and feet. The Veteran stated that since 2015, his feet get bigger and swell up to the point that he cannot wear shoes, lasting for almost 4 to 5 days. The Veteran reported being able to stand for approximately 2 hours before he would have to sit down. The Veteran's right foot disability is currently rated 10 percent disabling under DC 5279 from February 18, 2015. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. DC 5279 provides that metatarsalgia, unilateral or bilateral, warrants a maximum 10 percent rating. 38 C.F.R. § 4.71 (a). A June 2015 VA examination report reflects a diagnosis of metatarsalgia of the right foot, with the examiner noting that the Veteran walks with a normal gait. The examiner reported that a medial longitudinal arch is present bilaterally while the Veteran is standing in a full weight bearing position, noted diffuse tenderness over the dorsum of the first metatarsal head, normal sensation, and good distal capillary filling in the distal toes, and indicated that the neuro/sensory/vascular was grossly intact in distal and toes. The examiner noted that the Veteran reported pain in the right foot, no flare-ups, and no functional loss or impairment. There was no pain reported on use of the feet, the Veteran reported use of arch supports, and the Veteran had extreme tenderness of the plantar surfaces of the right foot, improved with use of orthopedic shoes or appliances. The examination report indicated that the Veteran did not have decreased longitudinal arch height of one or both feet on weight bearing, there was no evidence of marked deformity, marked pronation, and the weight bearing line did not fall over or medial to the great toe. The examiner reported that the Veteran did not have "inward" bowing of the achilles tendon, marked inward displacement and severe spasm of the Achilles tendon on manipulation of one or both feet, or Morton's neuroma. The examination report indicated that the Veteran did not have symptoms due to a hallux valgus condition or hallux rigidus, and had not had foot surgery. There was pain noted on physical examination, but the pain did not contribute to functional loss. The examiner reported that there was no pain, weakness, fatigability, or incoordination that significantly limited functional ability during flare-ups, or when the foot is used repeatedly over a period of time. Degenerative or traumatic arthritis was not documented, and the examiner opined that the Veteran's right foot disability did not impact his ability to perform any type of occupational task. In his January 2016 statement, the Veteran reported moderate foot pain, and stated that he had molds made to ease his pain, and that he uses arches in his shoes as well as cortisone shots. A March 2017 VA examination report indicates that the Veteran denies radiation of pain into his leg or other parts of his foot, giving out, swelling, or popping. The examiner noted that the Veteran walked with a normal gait and that medial longitudinal arch was present bilaterally while standing in a full weight bearing position. The Veteran reported pain, but no flare-ups that impact the function of the foot, no functional loss, and no functional impairment. The examiner noted that the Veteran did not use any assistive devices, and degenerative or traumatic arthritis was not documented. No pain was noted with weight bearing, non-weight bearing, or with passive range of motion. The Board finds that the evidence weighs against assignment of an initial rating in excess of 10 percent for the Veteran's service connected metatarsalgia. As previously noted, under DC 5279, a 10 percent rating is the maximum schedular rating available for metatarsalgia. 38 C.F.R. § 4.71a , DC 5279. Since the service connected disability, metatarsalgia, is specifically contemplated by DC 5279, the Board cannot rate the associated symptoms under an analogous DC. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). The Veteran does not have a diagnosis of flat foot, weak foot, claw foot, or hammertoes, and the record contains no evidence of any malunion or nonunion of the tarsal or metatarsal bones, so evaluation under DCs 5276, 5277, 5278, 5282 and 5283 is not warranted. The Board notes that there is also no diagnosis of plantar fasciitis warranting a rating under the new diagnostic code 5269. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). Additionally, the June 2015 and March 2017 examination reports reflect that that there is no evidence of hallux valgus, or hallux rigidus, thus separate ratings under DCs 5280 and 5291 are not warranted. Finally, while the Veteran and his representative testified that the Veteran had a diagnosis of right foot arthritis, the June 2015 and March 2017 examiners indicated that degenerative or traumatic arthritis was not documented. While the Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he has observed and is within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The record does not show, nor does the Veteran contend, that he has specialized education, training, or experience that would qualify him to render a diagnosis. Therefore, the Veteran's statements as to a diagnosis are afforded no probative weight, and are outweighed by the findings of the June 2015 and March 2017 examiners. Therefore, a separate rating under DC 5003 is not warranted. As to consideration of referral for an extraschedular rating, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those listed in the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (the Board is not obligated to analyze whether remand for referral for extraschedular consideration is warranted if "§ 3.321(b) (1) [is] neither specifically sought by [the claimant] nor reasonably raised by the facts found by the Board" (quoting Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007)). For the foregoing reasons, the preponderance of the evidence weighs against a rating higher than 10 percent for Veteran's right foot metatarsalgia. The benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. REASONS FOR REMAND TDIU The Veteran testified that he no longer works part-time because his employer needed a full-time worker, and he is unable to work full time as the long hours on his feet and climbing ladders cause swelling. He stated that when his feet swell, he has to stay home as he cannot wear boots. The Veteran reported calling in sick approximately twice a month due to swelling in his feet. The issue of entitlement to a TDIU has thus been raised as part and parcel of the claim for a higher initial rating for right foot metatarsalgia. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). The Veteran's form 21-8940 reflects that he completed 2 years of college, worked in construction, became too disabled to work and last worked full-time in December 2019, and that he reported that his PTSD, foot, and knee disabilities prevented him from securing or following any substantially gainful occupation. As the RO's implementation of the Board's grant of service connection for PTSD, right and left knee disabilities, and left foot disability contained herein could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. Therefore, a remand of the claim for TDIU is required. The matter is thus REMANDED for the following action: After implementing the grants of service connection for PTSD, right and left knee disabilities, and left foot disability, readjudicate the inextricably intertwined issue of entitlement to TDIU. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Maddox, 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.