Citation Nr: 21069908 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 14-22 930 DATE: November 22, 2021 ORDER Entitlement to service connection for a right wrist condition is denied. Entitlement to service connection for a left wrist condition is denied. Entitlement to service connection for a right elbow condition is denied. Entitlement to service connection for a left elbow condition is denied. Entitlement to service connection for a right hand condition is denied. Entitlement to service connection for a left hand condition is denied. Entitlement to a total disability rating based on individual unemployability as due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. The competent evidence does not demonstrate that any diagnosed right wrist condition is attributable to the Veteran's active service or any incident of service, to include as due to a service-connected disability. 2. The competent evidence does not demonstrate that any diagnosed left wrist condition is attributable to the Veteran's active service or any incident of service, to include as due to a service-connected disability. 3. The competent evidence does not demonstrate that any diagnosed right elbow condition is attributable to the Veteran's active service or any incident of service, to include as due to a service-connected disability. 4. The competent evidence does not demonstrate that any diagnosed left elbow condition is attributable to the Veteran's active service or any incident of service, to include as due to a service-connected disability. 5. The competent evidence does not demonstrate that any diagnosed right hand condition is attributable to the Veteran's active service or any incident of service, to include as due to a service-connected disability. 6. The competent evidence does not demonstrate that any diagnosed left hand condition is attributable to the Veteran's active service or any incident of service, to include as due to a service-connected disability. 7. The weight of the evidence fails to establish that the Veteran was unable to secure or follow substantially gainful employment due solely to service-connected disabilities at any point during the appeal period. CONCLUSIONS OF LAW 1. The criteria for service connection for a right wrist condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310; Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 2. The criteria for service connection for a left wrist condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310; Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 3. The criteria for service connection for a right elbow condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310; Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 4. The criteria for service connection for a left elbow condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310; Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 5. The criteria for service connection for a right hand condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310; Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 6. The criteria for service connection for a left hand condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310; Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 7. The criteria for entitlement to TDIU have not been met. 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1982 to June 1984. These matters were last before the Board in March 2021, whereupon they were remanded to the Agency of Original Jurisdiction (AOJ) for further development of the record. Following the issuance of an August 2021 supplemental statement of the case continuing the denial of these above-listed issues, the case was returned to the Board for its adjudication. As a reminder, the Veteran testified at an October 2019 videoconference hearing before the undersigned Veterans Law Judge. Service Connection Entitlement to service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Secondary service connection is permitted based on aggravation, such that compensation is payable for the degree of aggravation of a nonservice-connected disability caused by a service-connected disability. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439 (1995). Consequently, there exist two potential theories of entitlement to secondary service connection namely, causation under § 3.310(a) and aggravation under § 3.310(b). To the Board's knowledge, a portion of the Veteran's service medical records, to particularly include copies of his entrance and discharge examinations, have not been associated with the claims file. VA is required to obtain relevant documents held by any Federal department or agency that the Veteran adequately identifies and authorizes the Secretary to obtain. 38 U.S.C. § 5103A(c)(3); 38 C.F.R. § 3.159(e). The Board acknowledges that VA has a heightened duty to assist the Veteran in developing his claims since the records may have been lost, as well as an obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005); O'Hare v. Derwinski, 1 Vet. App. 365 (1991). Case law does not, however, lower the legal standard for proving a claim for service connection but simply increases the Board's obligation to consider that evidence which may be favorable to the Veteran. Russo v. Brown, 9 Vet. App. 46, 51 (1996). 1. Right and Left Wrist Conditions The Veteran seeks service connection generally for right and left wrist conditions as directly attributable to his service. In the alternative, he contends that both the right and left wrist conditions are secondary to his service-connected right knee condition. As the evidence in support of both claims is largely identical, the Board will consider them both together. The question for the Board is whether the Veteran has right and left wrist conditions that began during service or are at least as likely as not related to an in-service injury, event, or disease. In the alternative, the question for the Board is whether the Veteran's right and/or left wrist conditions were proximately caused by or aggravated by a service-connected disability, namely, the Veteran's right knee condition. The Board concludes that, while the Veteran has been diagnosed with right and left wrist gouty arthritis, the preponderance of the evidence is against a finding that either condition began during active service, or is otherwise related to an in-service injury, event, or disease, to include as secondary to a service-connected disability. 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), 3.310. A review of available service medical records does not show that the Veteran ever complained of wrist symptomatology, nor was he ever diagnosed with or treated for a right or left wrist condition, to specifically include gouty arthritis. As stated, there are no copies of the Veteran's discharge examination available in the claims file for review. Post-service, VA and private medical records do show treatment generally for gout and associated arthritis, but there is no documentation of the Veteran having received any specific treatment for right or left wrist conditions. During the October 2018 hearing, the Veteran related that he experienced pain and stiffness in his right and left wrists and reiterated his contention that both right and left wrist conditions were secondary to the service-connected right knee condition. The nature and likely etiology of the bilateral wrist conditions was first evaluated in a February 2020 VA wrist examination, during which the Veteran reported experiencing occasional stiffness in his wrists bilaterally as well as flare-ups of pain and stiffness during an attack of gout, which he asserted would occur about five or six times per year. According to the Veteran, these attacks of gout symptomatology had been occurring for the past 15 to 20 years. He related that when he experienced an attack of gout, he treated the symptomatology with oral steroids and pain medication. After an in-person examination, the Veteran was diagnosed with gouty arthritis affecting the wrists bilaterally. The examiner then opined that it was less likely than not that either the right or left wrist conditions were incurred in or were otherwise attributable to service, on the grounds that there was no documentation of treatment for wrist symptomatology or gouty arthritis while in service and for more than a year following the Veteran's discharge. The February 2020 examiner did not opine as to whether either the right or left wrist condition was secondary to a service-connected disability. Pursuant to the Board's March 2021 remand instructions, the claims file was evaluated by a VA medical professional, who issued addendum opinions regarding the likely etiology of the claimed right and left wrist conditions in May 2021. The chosen examiner first reiterated that it was less likely than not that either the right or left wrist conditions were incurred in or otherwise attributable to service, on the grounds that there was no documentation of treatment for wrist symptomatology or gouty arthritis while in service and for more than a year following the Veteran's discharge. As for the secondary service connection component, the examiner further opined that it was less likely than not that either the right or left wrist gouty arthritis was caused by or aggravated beyond its normal progression by the service-connected right knee condition. In support thereof, the examiner relied on the lack of medical literature that supported the notion that right knee arthrosis could contribute to the development of gouty arthritis in a separate joint, and stated that a "knee condition would not cause aggravation of a gout condition in a completely separate joint." See August 2021 Medical Opinion Disability Benefits Questionnaire. Furthermore, the examiner noted that the Veteran had many of the risk factors for the development of gouty arthritis, including his gender and age. As an aside, the Board is aware that section 3.310 does not utilize the "beyond its natural progression" language and has thus considered whether the opinion is adequate. Viewed in the full context of the opinion, the Board finds that the use of this language does not vitiate the opinion's probative value. Specifically, the Board finds that the examiner's statement that a knee condition "would not cause aggravation of a gout condition in a completely separate joint" to encompass the entirety of any possible aggravation, rather than just to the standard of "beyond the natural progression" that the examiner's written words would seem to suggest. In support of this opinion, the examiner relied on medical knowledge regarding the biomechanical functions of the knees and separate joints as well as the manifestation of gout in the body. Viewing all of this information together, the Board finds that there is no basis for a remand for a further opinion, as the opinion in total adequately addresses the prior remand query as to aggravation, and there is no reasonable likelihood that a further opinion would produce different findings. To that end, the Board acknowledges that several of the opinion reports concerning the likely etiology of the claimed issues before the Board, to include the right wrist condition, utilize language suggesting that the condition at issue (here, the right wrist gout condition) "clearly and unmistakably existed prior to service" and was not "aggravated beyond its natural progression" by the Veteran's right knee condition. Read within the context of the rest of the opinion reports of record, and in consideration of the lack of any contention by the Veteran that his right wrist condition existed prior to service, as well as the lack of any evidence to suggest this to be the case, the Board finds the use of this language to be a typographical error that is harmless. There is no separate theory of entitlement based on any of the conditions at issue in the present case to have preexisted service, and so there is no need for the Board to further evaluate such a theory as it applies to any of the conditions for which service connection is claimed. Finally, the Board also acknowledges that the examiner did not specifically address whether the right or left wrist condition was secondary to the newly service-connected left knee condition. However, the Board again relies on the examiner's rationale, and the language that a knee condition (either right OR left) "would not cause aggravation of a gout condition in a completely separate joint." Read in context, this language suggests that the examiner's conclusions regarding the potential nexus between the right knee condition and the conditions for which service connection is being sought is equally applicable to the newly service-connected left knee condition. As such, further development would be fruitless, and the Board may continue to rely on the May 2021 examiner's opinions regarding secondary service connection without pursuing any addendum opinion. Having addressed any and all potential deficiencies, the Board finds the February 2020 examination and opinion as well as the May 2021 addendum opinion to be highly probative, as in both instances the VA examiner reviewed the claims file, carried out an in-person examination, and referred to the Veteran's medical history in support of their conclusions. Sklar v. Brown, 5 Vet. App. 140 (1993). Of course, the February 2020 opinion necessitated remand as the examiner did not address secondary service connection. However, the Board still finds probative the opinions of the February 2020 examiner as to direct service connection for the claimed conditions. Upon consideration of the record, the Board finds that the preponderance of the evidence is against a determination that either the Veteran's left or right wrist condition is attributable to service. To begin, the service treatment records do not document any complaints or treatment related to either a right or left wrist condition. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Indeed, the Veteran himself has not asserted that the condition began in service. Moreover, as stated the Board finds highly probative the opinions of the February 2020 and May 2021 VA examiners, who confirmed the lack of in-service treatment for bilateral wrist symptomatology and further highlighted the lack of subsequent medical care for bilateral wrist symptomatology for several years following service. There is simply no competent evidence to support that the right and left wrist gouty arthritis first diagnosed several years after the Veteran's discharge is related to service. Accordingly, service connection for a right or left wrist condition on a direct basis pursuant to 38 C.F.R. § 3.303(a) is denied. The Veteran may still be entitled to service connection for right or left wrist conditions pursuant to his alternative theory of the conditions being secondary to the service-connected right knee disability. As detailed above, secondary service connection is based on either demonstrating that the condition at issue was proximately caused by a service-connected disability or that it was aggravated due to an underlying service-connected disability. 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 439. The Veteran has not offered any objective supporting medical evidence or any other rationale for his belief that his right and left wrist conditions were proximately caused by and/or aggravated by a service-connected disability, other than to suggest that gout in his right knee has spread throughout the rest of bilateral upper extremities. The Board also highlights the highly probative opinion of the May 2021 VA examiner, who found that it was less likely than not that the right knee disability (and, by extension, the newly service-connected left knee disability) contributed to the development of either the right or left wrist condition, either on a direct basis or on an aggravation basis. Accordingly, as there is no competent evidence in the record that supports the Veteran's contention that his right and left wrist conditions were proximately caused by or aggravated by his right knee disability, the Board finds that the preponderance of the evidence is against a determination that service connection is warranted for either a right or left wrist condition as secondary to a service-connected disability. The Veteran may still be entitled to service connection if all of the evidence establishes that the right and left wrist conditions were incurred in service. 38 C.F.R. § 3.303(d). Here, however, there is no evidence of incurrence in service, and again there is a several-year gap between discharge and when the Veteran first sought treatment for symptoms of right and left wrist conditions. He has not presented, and the claims file does not otherwise contain, any medical evidence supporting a causal link between a right or left wrist condition and his service. Furthermore, the Veteran's assertion that he has a right and/or left wrist condition that is attributable to service is outweighed by the opinions of the February 2020 and May 2021 VA examiners. Without any competent evidence in support of the claim to outweigh the probative negative etiology opinions of record, the Board finds that the preponderance of the evidence is against a determination that a medical nexus exists between the Veteran's right and left wrist gouty arthritis conditions and an in-service injury, event, or disease. Service connection for both a right and left wrist condition under 38 C.F.R. § 3.303(d) is denied, and as such the Veteran's claim of entitlement to service connection for both right and left wrist conditions in total must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As the preponderance of the evidence is against the Veteran's claim of service connection for right and left wrist conditions, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). 2. Right and Left Elbow Conditions The Veteran seeks service connection generally for right and left elbow conditions as directly attributable to his service. In the alternative, he contends that both the right and left elbow conditions are secondary to his service-connected right knee condition. As the evidence in support of both claims is largely identical, the Board will consider them both together. The question for the Board is whether the Veteran has right and left elbow conditions that began during service or are at least as likely as not related to an in-service injury, event, or disease. In the alternative, the question for the Board is whether the Veteran's right and/or left elbow conditions were proximately caused by or aggravated by a service-connected disability, namely, the Veteran's right knee condition. The Board concludes that, while the Veteran has been diagnosed with right and left elbow gouty arthritis, the preponderance of the evidence is against a finding that either condition began during active service, or is otherwise related to an in-service injury, event, or disease, to include as secondary to a service-connected disability. 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), 3.310. A review of available service medical records does not show that the Veteran ever complained of elbow symptomatology, nor was he ever diagnosed with or treated for a right or left elbow condition, to specifically include gouty arthritis. As stated, there are no copies of the Veteran's discharge examination available in the claims file for review. Post-service, VA and private medical records do show treatment generally for gout and associated arthritis, but there is no documentation of the Veteran having received any specific treatment for right or left elbow conditions. During the October 2018 hearing, the Veteran related that he experienced soreness and swelling in his right and left elbows and reiterated his contention that both right and left elbow conditions were secondary to the service-connected right knee condition. The nature and likely etiology of the bilateral elbow conditions was first evaluated in a February 2020 VA elbow examination, during which the Veteran reported experiencing occasional stiffness in his elbows bilaterally as well as flare-ups of pain and stiffness during an attack of gout, which he asserted would occur about five or six times per year. According to the Veteran, these attacks of gout symptomatology had been occurring for the past 15 to 20 years. He related that when he experienced an attack of gout, he treated the symptomatology with oral steroids and pain medication. He also noted that he would use a sling or braces depending on the severity of associated pain during a gout attack. After an in-person examination, the Veteran was diagnosed with gouty arthritis affecting the elbows bilaterally. The examiner then opined that it was less likely than not that either the right or left elbow conditions were incurred in or otherwise attributable to service, on the grounds that there was no documentation of treatment for elbow symptomatology or gouty arthritis while in service and for more than a year following the Veteran's discharge. The February 2020 examiner did not opine as to whether either the right or left elbow condition was secondary to a service-connected disability. Pursuant to the Board's March 2021 remand instructions, the claims file was evaluated by a VA medical professional, who issued addendum opinions regarding the likely etiology of the claimed right and left elbow conditions in May 2021. The chosen examiner first reiterated that it was less likely than not that either the right or left elbow conditions were incurred in or otherwise attributable to service, on the grounds that there was no documentation of treatment for elbow symptomatology or gouty arthritis while in service and for more than a year following the Veteran's discharge. As for the secondary service connection component, the examiner further opined that it was less likely than not that either the right or left elbow gouty arthritis was caused by or aggravated beyond its normal progression by the service-connected right knee condition. In support thereof, the examiner relied on the lack of medical literature that supported the notion that right knee arthrosis could contribute to the development of gouty arthritis in a separate joint, and stated that a "knee condition would not cause aggravation of a gout condition in a completely separate joint." See August 2021 Medical Opinion Disability Benefits Questionnaire. Furthermore, the examiner noted that the Veteran had many of the risk factors for the development of gouty arthritis, including his gender and age. Without reiterating the analysis detailed above on pp. 6-7, the Board incorporates its finding that the opinions promulgated by the May 2021 examiner are legally and factually sufficient and parallel to the wrist opinions, and that remand is unnecessary to satisfy the Board's duty to assist in this matter with regards to the separate claims of entitlement to service connection for right and left elbow conditions. As such, the Board finds the February 2020 examination and opinion as well as the May 2021 addendum opinions to be highly probative, as in both instances the VA examiner reviewed the claims file, carried out an in-person examination, and referred to the Veteran's medical history in support of their conclusions. Sklar, supra. Of course, the February 2020 opinion necessitated remand as the examiner did not address secondary service connection; however, the Board still finds probative the opinions of the February 2020 examiner as to direct service connection for the claimed conditions. Upon consideration of the record, the Board finds that the preponderance of the evidence is against a determination that either the Veteran's left or right elbow condition is attributable to service. To begin, the service treatment records do not document any complaints or treatment related to either a right or left elbow condition. See Buchanan, supra. Indeed, the Veteran himself has not asserted that the conditions began in service. Moreover, as stated the Board finds highly probative the opinions of the February 2020 and May 2021 VA examiners, who confirmed the lack of in-service treatment for bilateral elbow symptomatology and further highlighted the lack of subsequent medical care for bilateral elbow symptomatology for several years following service. There is simply no competent evidence to support that the right and left elbow gouty arthritis first diagnosed several years after the Veteran's discharge is related to service. Accordingly, service connection for a right or left elbow condition on a direct basis pursuant to 38 C.F.R. § 3.303(a) is denied. The Veteran may still be entitled to service connection for right or left elbow conditions pursuant to his alternative theory of the conditions being secondary to the service-connected right knee disability. As detailed above, secondary service connection is based on either demonstrating that the condition at issue was proximately caused by a service-connected disability or that it was aggravated due to an underlying service-connected disability. 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 439. The Veteran has not offered any objective supporting medical evidence or any other rationale for his belief that his right and left elbow conditions were proximately caused by and/or aggravated by a service-connected disability, other than to suggest that gout in his right knee has spread throughout the rest of bilateral upper extremities. The Board also highlights the highly probative opinion of the May 2021 VA examiner, who found that it was less likely than not that the right knee disability (and, by extension, the newly service-connected left knee disability) contributed to the development of either the right or left elbow condition, either on a direct basis or on an aggravation basis. Accordingly, as there is no competent evidence in the record that supports the Veteran's contention that his right and left elbow conditions were proximately caused by or aggravated by his right knee disability, the Board finds that the preponderance of the evidence is against a determination that service connection is warranted for either a right or left elbow condition as secondary to a service-connected disability. The Veteran may still be entitled to service connection if all of the evidence establishes that the right and left elbow conditions were incurred in service. 38 C.F.R. § 3.303(d). Here, however, there is no evidence of incurrence in service, and again there is a several-year gap between discharge and when the Veteran first sought treatment for symptoms of right and left elbow conditions. He has not presented, and the claims file does not otherwise contain, any medical evidence supporting a causal link between a right or left elbow condition and his service. Furthermore, the Veteran's assertion that he has a right and/or left elbow condition that is attributable to service is outweighed by the opinions of the February 2020 and May 2021 VA examiners. Without any competent evidence in support of the claim to outweigh the probative negative etiology opinions of record, the Board finds that the preponderance of the evidence is against a determination that a medical nexus exists between the Veteran's right and left elbow gouty arthritis conditions and an in-service injury, event, or disease. Service connection for both a right and left elbow condition under 38 C.F.R. § 3.303(d) is denied, and as such the Veteran's claim of entitlement to service connection for both right and left elbow conditions in total must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As the preponderance of the evidence is against the Veteran's claim of service connection for right and left elbow conditions, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). 3. Right and Left Hand Conditions The Veteran seeks service connection generally for right and left hand conditions as directly attributable to his service. In the alternative, he contends that both the right and left hand conditions are secondary to his service-connected right knee condition. As the evidence in support of both claims is largely identical, the Board will consider them both together. The question for the Board is whether the Veteran has right and left hand conditions that began during service or are at least as likely as not related to an in-service injury, event, or disease. In the alternative, the question for the Board is whether the Veteran's right and/or left hand conditions were proximately caused by or aggravated by a service-connected disability, namely, the Veteran's right knee condition. The Board concludes that, while the Veteran has been diagnosed with right and left hand gouty arthritis, the preponderance of the evidence is against a finding that either condition began during active service, or is otherwise related to an in-service injury, event, or disease, to include as secondary to a service-connected disability. 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), 3.310. A review of available service medical records does not show that the Veteran ever complained of hand symptomatology, nor was he ever diagnosed with or treated for a right or left hand condition, to specifically include gouty arthritis. As stated, there are no copies of the Veteran's discharge examination available in the claims file for review. Post-service, VA and private medical records do show treatment generally for gout and associated arthritis, but there is no documentation of the Veteran having received any specific treatment for right or left hand conditions. During the October 2018 hearing, the Veteran related that he experienced pain and stiffness in his right and left hands and reiterated his contention that both right and left hand conditions were secondary to the service-connected right knee condition. The nature and likely etiology of the bilateral hand conditions was first evaluated in a February 2020 VA hand examination, during which the Veteran reported experiencing occasional stiffness in his hands bilaterally as well as flare-ups of pain and stiffness during an attack of gout, which he asserted would occur about five or six times per year. According to the Veteran, these attacks of gout symptomatology had been occurring for the past 15 to 20 years. He related that when he experienced an attack of gout, he treated the symptomatology with oral steroids and pain medication, and would sometimes wear a brace. After an in-person examination, the Veteran was diagnosed with gouty arthritis affecting the hands bilaterally. The examiner then opined that it was less likely than not that either the right or left hand conditions were incurred in or otherwise attributable to service, on the grounds that there was no documentation of treatment for hand symptomatology or gouty arthritis while in service and for more than a year following the Veteran's discharge. The February 2020 examiner did not opine as to whether either the right or left hand condition was secondary to a service-connected disability. Pursuant to the Board's March 2021 remand instructions, the claims file was evaluated by a VA medical professional, who issued addendum opinions regarding the likely etiology of the claimed right and left hand conditions in May 2021. The chosen examiner first reiterated that it was less likely than not that either the right or left hand conditions were incurred in or otherwise attributable to service, on the grounds that there was no documentation of treatment for hand symptomatology or gouty arthritis while in service and for more than a year following the Veteran's discharge. As for the secondary service connection component, the examiner further opined that it was less likely than not that either the right or left hand gouty arthritis was caused by or aggravated beyond its normal progression by the service-connected right knee condition. In support thereof, the examiner relied on the lack of medical literature that supported the notion that right knee arthrosis could contribute to the development of gouty arthritis in a separate joint, and stated that a "knee condition would not cause aggravation of a gout condition in a completely separate joint." See August 2021 Medical Opinion Disability Benefits Questionnaire. Furthermore, the examiner noted that the Veteran had many of the risk factors for the development of gouty arthritis, including his gender and age. Without reiterating the analysis detailed above on pp. 6-7, the Board incorporates its finding that the opinions promulgated by the May 2021 examiner are legally and factually sufficient and parallel to the wrist opinions, and that remand is unnecessary to satisfy the Board's duty to assist in this matter with regards to the separate claims of entitlement to service connection for right and left hand conditions. As such, the Board finds the February 2020 examination and opinion as well as the May 2021 addendum opinions to be highly probative, as in both instances the VA examiner reviewed the claims file, carried out an in-person examination, and referred to the Veteran's medical history in support of their conclusions. Sklar, supra. Of course, the February 2020 opinion necessitated remand as the examiner did not address secondary service connection. However, the Board still finds probative the opinions of the February 2020 examiner as to direct service connection for the claimed conditions. Upon consideration of the record, the Board finds that the preponderance of the evidence is against a determination that either the Veteran's left or right hand condition is attributable to service. To begin, the service treatment records do not document any complaints or treatment related to either a right or left hand condition. See Buchanan, supra. Indeed, the Veteran himself has not asserted that the condition began in service. Moreover, as stated the Board finds highly probative the opinions of the February 2020 and May 2021 VA examiners, who confirmed the lack of in-service treatment for bilateral hand symptomatology and further highlighted the lack of subsequent medical care for bilateral hand symptomatology for several years following service. There is simply no competent evidence to support that the right and left hand gouty arthritis first diagnosed several years after the Veteran's discharge is related to service. Accordingly, service connection for a right or left hand condition on a direct basis pursuant to 38 C.F.R. § 3.303(a) is denied. The Veteran may still be entitled to service connection for right or left hand conditions pursuant to his alternative theory of the conditions being secondary to the service-connected right knee disability. As detailed above, secondary service connection is based on either demonstrating that the condition at issue was proximately caused by a service-connected disability or that it was aggravated due to an underlying service-connected disability. 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 439. The Veteran has not offered any objective supporting medical evidence or any other rationale for his belief that his right and left hand conditions were proximately caused by and/or aggravated by a service-connected disability, other than to suggest that gout in his right knee has spread throughout the rest of bilateral upper extremities. The Board also highlights the highly probative opinion of the May 2021 VA examiner, who found that it was less likely than not that the right knee disability (and, by extension, the newly service-connected left knee disability) contributed to the development of either the right or left hand condition, either on a direct basis or on an aggravation basis. Accordingly, as there is no competent evidence in the record that supports the Veteran's contention that his right and left hand conditions were proximately caused by or aggravated by his right knee disability, the Board finds that the preponderance of the evidence is against a determination that service connection is warranted for either a right or left hand condition as secondary to a service-connected disability. The Veteran may still be entitled to service connection if all of the evidence establishes that the right and left hand conditions were incurred in service. 38 C.F.R. § 3.303(d). Here, however, there is no evidence of incurrence in service, and again there is a several-year gap between discharge and when the Veteran first sought treatment for symptoms of right and left hand conditions. He has not presented, and the claims file does not otherwise contain, any medical evidence supporting a causal link between a right or left hand condition and his service. Furthermore, the Veteran's assertion that he has a right and/or left hand condition that is attributable to service is outweighed by the opinions of the February 2020 and May 2021 VA examiners. Without any competent evidence in support of the claim to outweigh the probative negative etiology opinions of record, the Board finds that the preponderance of the evidence is against a determination that a medical nexus exists between the Veteran's right and left hand gouty arthritis conditions and an in-service injury, event, or disease. Service connection for both a right and left hand condition under 38 C.F.R. § 3.303(d) is denied, and as such the Veteran's claim of entitlement to service connection for both right and left hand conditions in total must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As the preponderance of the evidence is against the Veteran's claim of service connection for right and left hand conditions, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). TDIU Total disability ratings for compensation based on individual unemployability may be assigned when the combined schedular rating for the claimant's service-connected disabilities is less than 100 percent, and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or, if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities sufficient to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). The Veteran's service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. To that end, the Board notes that from August 1, 2013, the Veteran was in receipt of a 30 percent rating for degenerative arthrosis of the right knee. Pursuant to the recent August 2021 rating decision, the Veteran has also been assigned a 10 percent rating for left knee arthritis effective November 4, 2013. The present combined rating is 40 percent. Thus, the Veteran has not met the schedular requirements for a grant of TDIU at any point during the appeal period. That being said, the Veteran may be entitled to a grant of TDIU on an extraschedular basis, provided that the record shows that he was nevertheless unemployable on account of his service-connected disabilities. 38 C.F.R. § 4.16(b). The Board is precluded from assigning a TDIU rating on an extraschedular basis in the first instance. Instead, the Board must refer any claim that meets the criteria for referral for consideration of entitlement to TDIU on an extraschedular basis to the Director, Compensation and Pension Service. Bowling v. Principi, 15 Vet. App. 1 (2001). To begin, the Board notes that the United States Court of Appeals for Veterans Claims (Court) recently promulgated additional guidance to assist in the evaluation of claims for TDIU in Ray v. Wilkie, 31 Vet. App. 58, 71 (2019). The Court stated that: "[W]e interpret the phrase "unable to secure and follow a substantially gainful occupation" in [38 C.F.R.] § 4.16(b) to have two components: one economic and one noneconomic. The economic component simply means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. As for the noneconomic component, the Secretary himself stated that 'determining eligibility for TDIU requires more than determining the presence or absence of employment producing income exceeding any particular threshold,' and 'the ultimate inquiry is instead on the individual claimant's ability to secure or follow that type of employment.'" Factors for consideration in evaluating the noneconomic component are: (1) the veteran's history, education, skill, and training; (2) whether the veteran has the physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and (3) whether the veteran has the mental ability to perform the activities required by the occupation at issue, with possibly relevant factors including, but not limited to, the limitations, if any, concerning memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity. Id. With regard to the economic component of the Ray analysis, the Veteran has submitted three separate application forms in support of his TDIU claim on VA From 21-8940, dated in August 2014, February 2015, and in November 2019. On each application he indicated that his right knee condition prevented him from securing or following any substantially gainful occupation. On the applications dated in August 2014 and in February 2015, he reported that his right knee condition first affected his full-time employment in January 2009 and that he last worked full time in January 2010 as a television engineer. On the more recent November 2019 application, he instead indicated that he last worked full time as a technician in August 2013. In any event, it is clear that the Veteran did not earn any income from employment during the appeal period. As such, the Board finds that the economic component of the Ray analysis has been satisfied. Without dismissing the economic component of a TDIU grant under the guidelines set forth in Ray, a referral for extraschedular consideration of TDIU is still not warranted unless the record suggests that any degree of unemployability was attributable to the Veteran's service-connected disabilities. After a thorough review of the record, the Board does not find that the Veteran's service-connected right and left knee conditions together precluded him from securing and following substantially gainful employment at any point in time during the appeal period. Regarding the noneconomic component defined in Ray, the Board notes that on the February 2015 TDIU application the Veteran detailed that he completed one year of undergraduate education and had no further training or education. He related that his job as a television engineer became too physically and mentally challenging due to having to climb, bend, and stand for long periods of time. He also noted that he was unable to sit for more than a very short period of time before he had to get up because his knees would become too stiff and painful. According to the Veteran, he often missed work due to his knee symptomatology. The Veteran was afforded a VA knee examination in August 2016, during which it was noted that the Veteran only had a diagnosable right knee arthrosis condition status-post total knee replacement surgery in 2012. Although he did not endorse experiencing any flare-ups of symptomatology, the Veteran did report experiencing weakness and instability with prolonged standing or walking. Range of motion testing revealed flexion limited to 100 degrees with no further loss of extension. The examiner also noted pain with weightbearing as well as the right knee being tender to palpation at medial and especially the lateral joint line. There was no evidence of crepitus or ankylosis, but instability testing did reveal mild anterior instability and moderate lateral instability. Following repetitive use testing, the examiner noted that pain and fatigue would significantly limit functional ability, such that prolonged standing or walking would cause knee instability and prevent the Veteran from climbing or descending stairs. The examiner also noted the following additional factors contributing to disability: less movement than normal, instability of station, disturbance of locomotion, and interference with standing. In summation, it was the examiner's impression that the right knee condition would not result in any impairment of occupational functioning. During the April 2018 hearing, the Veteran detailed that he experienced soreness, looseness, weakness, and swelling in his right knee. According to the Veteran, he had difficulty with ambulation and utilized a cane as well as a knee brace to assist with walking. He also noted that many of the symptoms he was experiencing in his right knee were slowly manifesting in his left knee. Pursuant to the Board's March 2019 remand instructions, the Veteran was scheduled for a new VA knee examination in February 2020. The Veteran did not endorse experiencing any flare-ups of symptomatology, although he did report that his bilateral knees would hurt with prolonged standing, sitting or walking. Range of motion testing revealed right knee flexion reduced to 90 degrees while left knee flexion was reduced to 100 degrees. There was no loss of extension, crepitus, pain with weightbearing or ankylosis bilaterally. However, the examiner did note minor tenderness to palpation at the joint line in both knees. It was also noted that the Veteran did not experience any additional loss of functioning in either knee following repetitive use testing. The examiner did highlight that the left knee would swell intermittently and that the swelling was improved with pain medication, elevation and topical application of heat. It was the examiner's impression that the right knee replacement surgery resulted in intermediate degrees of residual weakness, pain, and/or limitation of motion. The examiner also commented that the knee conditions together would impair occupational functioning but stated only that the Veteran would be able to do sedentary work and provided no further clarification. A review of post-service VA medical records shows that the Veteran complained of and received treatment for right knee pain for the entirety of the appeal period. period. An August 2014 outpatient note reflects that the Veteran fell on his right knee when it gave out while he was working outside. He reported experiencing significant right knee pain following the injury. A subsequent August 2014 evaluation indicated that an x-ray examination did not reveal any fracture, although there was increased uptake and moderate effusion of the right knee. Thereafter, an March 2015 outpatient note shows that the Veteran reported instability and right knee pain. An evaluation revealed flexion limited to 130 degrees, no effusion, and varus laxity. An August 2015 outpatient note indicates that the Veteran reported continuing pain and instability of his right knee. Flexion was limited to 130 degrees, and stability testing showed significant laxity. The examiner discussed a possible revision knee replacement. Subsequent records show continued treatment for right knee pain and instability, to include physical therapy. There is no indication from the record that the Veteran did undergo any additional right knee surgery. A review of post-service private medical records reflects that the Veteran has been receiving treatment for bilateral knee symptomatology through his private physician for the entirety of the appeal period. During an April 2011 evaluation by a Dr. S.I., the Veteran reported difficulty with walking, especially when his right knee swelled. Flexion was measured at 90 degrees with no limitation of motion. A November 2013 evaluation report indicated that the Veteran was experiencing a gradual increase of right knee pain beginning about a year prior following his knee replacement surgery. According to the Veteran, his pain accompanied any walking, sitting, use of steps, and/or physical activity. Flexion was measured at 100 degrees with no limitation of extension. No instability was noted, although the examiner did find evidence of effusion and tenderness along the lateral joint line. An X-ray examination did not reveal any abnormalities or problems with the prosthesis. Thereafter, a June 2017 X-ray examination report from a W.H. revealed a photopenic defect as well as uptake surrounding the knee arthroplasty involving the femoral and tibial components. In an August 2014 correspondence, the Veteran's daughter, a C.K., stated that the Veteran's knee conditions caused him so much pain that he was unable to get out of bed on certain days. According to C.K., the Veteran's physical impairments caused him to lose his job and prevented him from securing new employment. Similarly, in a September 2018 correspondence C.K. again detailed that the Veteran's physical ailments' especially his knees, precluded him from engaging in physical activity and also prevented him functioning in an occupational setting. In a separate correspondence received by VA in September 2014, a W.K. related that the Veteran's right knee condition caused him to miss hours and days of work and eventually resulted in the termination of his employment. According to W.K. the Veteran still experienced chronic pain, swelling and instability that interfered with his ability to secure new employment. In an October 2014 correspondence, a D.P., who identified herself as the Veteran's former supervisor in his position as an engineer, stated that the Veteran missed several weeks of work due to his knee conditions. According to D.P., the Veteran's job duties required that he walk and climb regularly, which his knee conditions prevented him from doing. She also detailed that the Veteran was required to be on call at all hours and was unable to do so under the influence of pain medication. In addition, D.P. related that the Veteran had to be sent home when he experienced too much pain or became disoriented at work. Pursuant to VA's request for information, the Veteran's former employer submitted correspondence dated in April 2015 concerning the circumstances of the Veteran's previous employment with the company. According to the individual who prepared the information request document, the Veteran worked with the company from October 1997 to January 2011, and was employed doing engineering, which entailed climbing, crawling, and reaching up high. In total, the work was characterized as being "very physical". When queried as to the reason for the Veteran's job being terminated, the individual who prepared the document stated that the Veteran "could not meet the physical requirements to perform duties required for" the job. It was also noted that the job required that the Veteran work with high voltage equipment. Taken together, this evidence does not illustrate that the Veteran was precluded from engaging in substantially gainful employment solely by virtue of his service-connected bilateral knee disability. While the question of whether a veteran is capable of substantially gainful employment is ultimately one for the adjudicator (see Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013)), the fact that neither VA examiner who evaluated the severity of the service-connected knee disabilities during the applicable appeal period found that the knee conditions would preclude the Veteran from securing and following substantially gainful employment is consistent with the rest of the medical evidence of record. Thus, the Board considers those examinations to be highly probative. While the record does reflect that the Veteran was restricted in his ability to sit or ambulate for extended periods of time, this degree of impairment does not suggest that he was precluded from physically performing sedentary, light or even medium work. Indeed, although the Board acknowledges that the record reflects that the Veteran was let go from his position as an engineer as due at least in part to the impairment from his service-connected knee disabilities, the evidence also suggests that his work was highly specialized and required a standard of physical ability that would not necessarily be required in many other types of work. There is no indication from the record as to the extent that the Veteran attempted to secure other types of work that were not as physically demanding or the extent to which the Veteran's bilateral knee disabilities would impair his occupational functioning in more sedentary positions, other than the highly probative opinions of the two VA examiners of record. The Board has considered the Veteran's assertions that he was unable to work as a result of his service-connected disabilities. However, the Veteran does not possess training or credentials in medical or vocational matters and, thus, cannot competently opine on the question of whether such symptoms actually rendered him unemployable during the period in question. Jandreau v. Nicholson, 491 F.3d 1372 (Fed. Cir. 2007). The Board also acknowledges that the Veteran was unemployed during the appeal period. However, the mere fact that a Veteran is unemployed or underemployed, or has difficulty obtaining employment, is not enough to warrant a grant of TDIU. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Indeed, the Court in Ray reemphasized that the question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether such veteran can find employment. In summation, the Board finds the preponderance of the evidence is against a determination that the Veteran's service-connected disabilities precluded him from securing and following substantially gainful employment during the appeal period. The appeal is denied and will not be referred for extraschedular consideration. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher M. Collins, 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.