Citation Nr: 21074759 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 14-28 530A DATE: December 16, 2021 ORDER A rating in excess of 10 percent for a left knee disability based on limitation of motion is denied. A separate disability rating of 10 percent for a left knee instability is granted. Entitlement to service connection for a right ankle disability is denied. Entitlement to service connection for a left ankle disability is denied. FINDINGS OF FACTS 1. During the period on appeal, the Veteran's flexion was not shown to be functionally limited to 30 degrees or less, nor was his extension limited to 10 degrees or greater. 2. The Veteran's left knee condition is also manifested by slight instability. 3. The weight of the evidence does not show that the Veteran's bilateral ankle condition had onset in or was caused by service, nor has the evidence shown that it was caused or aggravated by his service-connected disabilities to include his low back disability and/or his knee disabilities. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for a left knee disability based on limitation of motion have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5260, 5261. 2. The criteria for a separate rating of 10 percent for a left knee disability manifested by instability, have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5257. 3. The criteria for service connection for a right ankle disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 4. The criteria for service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1990 to 1993. This matter is on appeal from a February 2013 rating decision and was most recently remanded by the Board in May 2021. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran contends that his left knee disability warrants a rating higher than 10 percent. By way of history, the Veteran was initially granted service connection for a left knee disorder by an April 1996 rating decision and was assigned a 10 percent. While he had previously filed for a higher rating, he did not perfect an appeal. He ultimately filed a new increased rating claim in November 2010, asserting that his condition had worsened. See November 2010 VA 21-526b Veterans Supplemental Claim. The Veteran's left knee internal derangement has been rated for limited flexion under Diagnostic Code 5260. Knee disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 to 5263. Included within 38 C.F.R. § 4.71a are multiple diagnostic codes that evaluate impairment resulting from service-connected knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). Additionally, if the knee condition involves arthritis, the knee disability may be rated under provisions for evaluating arthritis. Arthritis due to trauma is rated as degenerative arthritis according to Diagnostic Code 5003. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, the disability is to be rated as follows: with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, 20 percent; with X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5003. 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). Specifically, under Diagnostic Code 5257, was changed to include patellar instability. If a law or regulation changes during the course of 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. The Board specifically notes that the amendments do not pertain to all diagnostic codes pertaining to the knee. Rather the revisions involved diagnostic codes 5257 relating to instability and 5262 relating to impairment of the tibia or fibula. The Veteran indicated that his knee felt "rubbery," which made him feel as if he would fall. He installed handicap railings in his shower to help with balance. He experienced numbness down his left side from his buttocks to his feet. He tried various boots and shoes that may help relieve pain, but to no avail. Because of the pain, he no longer drives his manual car and had to purchase a new car with an automatic transmission. See December 2010 Correspondence. The Veteran was afforded a VA examination in December 2010. There, he complained of progressively severe pain and dysfunction with his left knee, which gave out twice a day, usually in the morning. While he denied locking sensations, he complained of stiffness which limits his walking distance. He reported constant and moderate pain, which becomes more severe during a flare up. Such flare ups occur approximately 20 times per day, lasting about 30 seconds to two minutes. He requires over the counter pain medication to relieve his symptoms. He reported impairment in kneeling, squatting, climbing stairs, and running. He can no longer drive his motorcycle because he is unable to switch gears. Upon a physical examination, the Veteran demonstrated pain with motion. His forward flexion was to 97 degrees and extension to 3 degrees with pain. After repetitions of range of motion, his range of motion was 3 degrees to 140 degrees with tenderness. In his final remarks, the examiner noted that there was major functional impact due to weakness, fatigue, lack of endurance, or incoordination. There was no evidence of inflammation, neoplasm, or mechanical ligamentous instability of the left knee. In his November 2012 statement, the Veteran indicated that he uses a knee brace and ice to alleviate his symptoms. Walking on his left leg could cause pain from his back down to his leg and toes. While changing his walk helps, it affects his ankle. The Veteran was afforded a new VA examination in February 2013. A range of motion testing initially revealed a forward flexion to 110 degrees with pain. His extension was to 5 degrees with pain. He was able to perform a repetitive use testing with at least three repetitions without resulting in additional loss of motion. He reported functional impairment due to symptoms such as less movement than normal, weakened movement, excess fatigability, and pain on movement. He reported pain and tenderness to palpation of the joint line or soft tissue of the knee. A muscle strength test revealed a slight reduction in strength with a score of 4 out of 5 in the left knee flexion and extension. A joint stability test showed normal results in anterior, posterior, and lateral stability. There was no history or evidence of recurrent patellar subluxation or dislocation. There was also no indication of a meniscal condition of the left knee. There was no history of a total knee joint replacement or any other arthroscopic surgery at this point. Further diagnostic testing showed no evidence of degenerative or traumatic arthritis over the left knee. In March 2013 correspondence, the Veteran indicated that because of his chronic left knee pain, he has had to change the way he walks, sits, and sleeps. While changing the positions eases his knee pain, the pain has increased in his back and bilateral ankles. He has been relying on ibuprofen for over 20 years and have seen little improvement. Based on another examination in April 2014, the Veteran continued to complain of left knee pain. The Veteran reported flare ups in his left knee. An initial range of motion testing showed that he had a forward flexion of 140 degrees with pain beginning at 45 degrees. His left knee extension was to 0 degrees. He was able to complete a repetitive use testing with at least three repetitions without resulting in additional loss of range of motion. He reported functional loss and functional impairment due to symptoms such as excess fatigability, pain on movement, and swelling. He reported pain or tenderness to palpation of the joint line or soft tissue of the knee. A muscle strength test revealed normal strength in both left knee flexion and extension with a score of five out of five. A joint instability test revealed no issues with instability. The examiner noted that there was no evidence or history of recurrent patellar subluxation or dislocation. There was no evidence of a meniscal condition or evidence of a total knee replacement of the left side. He denied using any assistive devices for support. Diagnostic testing revealed evidence of degenerative or traumatic arthritis of the left knee. The Veteran reported functional impact and uses a knee brace for work. When the matter came to the Board in July 2018, it was remanded for a new medical opinion as it found that the previous examinations did not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Additionally, the April 2014 VA examiner estimated that the Veteran is "about 75% of current normal when flared." The Board found the statement vague and did not adequately address functional loss during a flare up. The Veteran was then afforded a new VA examination in March 2019 to re-assess the severity of his left knee condition. There, he reported flare-ups of the left and right knees approximately 2 to 3 times per week, which caused moderate pain. The examiner indicated that with flare-ups of his knees, the Veteran may not be able to flex his left knee past 100 degrees. His initial range of motion revealed a forward flexion to 115 degrees and extension to 0 degrees. Because of pain, he avoids motions such as bending, stooping, squatting, kneeling, crawling, frequent climbing, prolonged standing and walking, running, and moderate to heavy lifting, pushing and pulling. There was objective evidence of pain with weight bearing and localized tenderness or pain on palpation of the joint, and crepitus. He was able to complete a repetitive use testing with at least three repetitions without resulting in additional functional loss and range of motion. Further evaluation noted that upon repeated use, pain, weakness, fatigability, or incoordination do not significantly limit functional ability. However, with flare-ups, the Veteran's range of motion is estimated to be only 100 degrees in flexion and 0 degrees extension. A muscle strength test revealed normal strength in both flexion and extension of the right knee, with a score of five out of five. There was no evidence of muscle atrophy or ankylosis in the left knee. A joint stability test revealed no problems with recurrent subluxation, lateral instability, or recurrent effusion. There was no evidence of a meniscal condition or indication of prior surgery. The Veteran reported using a brace on a regular basis. In his final remarks, the examiner noted that there was evidence of pain in non-weight bearing motion as well as pain on passive range of motion. The Veteran was afforded another examination in September 2020. An initial range of motion testing revealed a forward flexion to 105 degrees, with pain, and extension to zero degrees. There was no evidence of localized tenderness, pain, and crepitus. He was able to complete a repetitive use testing with at least three repetitions without resulting in additional loss of range of motion or functional loss. The examiner noted that upon repeated use, symptoms such as pain, weakness, fatigability, or incoordination significantly limit functional ability overtime. His estimated range of motion after repeated use remained at 105 degrees flexion and 0 degrees extension. While the examination was not conducted during a flare up, the examiner estimated that the Veteran's forward flexion an extension remained the same. A muscle strength test revealed normal strength in both flexion and extension of the left knee, with a score of five out of five. There was no evidence of muscle atrophy or ankylosis of the left knee. Joint stability tests revealed no abnormalities. There was no evidence of recurrent subluxation, lateral instability, or recurrent effusion. The examiner found no evidence of a meniscal condition or signs of a surgical procedure conducted on the left knee. The Veteran denied using any assistive devices to help with locomotion. Regarding functional impact, the Veteran was advised against repetitive bending of the knee such as climbing stairs, squatting, and bending down. Pursuant to Correia, the examiner found objective evidence of pain on non-weight bearing motion and passive motion. In the April 2021 Appellate Brief, the Veteran argued that the 2020 VA examination was inadequate as it failed to adequately account for the Veteran's pain and discomfort, as well as decreased range of motion after repetitive use. When the matter came to the Board in May 2021, it was again remanded for a new examination. The Board agreed with the Veteran and found that the 2020 VA examination failed to determine the degree at which pain occurred on motion, despite finding functional loss on flexion. The Veteran was afforded a new VA examination in June 2021. There, he continued to demonstrate an abnormal range of motion. He reported that despite physical therapy, he has limitations with carrying heavy objects, picking up things off the ground, lifting his legs, squatting, using stairs, prolonged walking, running, and hiking. He indicated that his left knee is in pain approximately 95 percent of the time with sensations of popping, adding that it gives way, requiring the use of a brace, especially at work. He denied any locking. His flexion was to 105 degrees and extension to 0 degrees on both active and passive motion. The Veteran reported pain in his flexion, with weight-bearing, active, and passive motion. Due to pain on weight-bearing, his flexion was limited to 75 degrees, with no pain on extension. There was objective evidence of crepitus, localized tenderness and pain on palpation of the joint. He was able to complete a repetitive use test with at least three repetitions without resulting in additional loss of range of motion or functional loss. It was noted that the Veteran was not examined immediately after repeated use over time or flare-ups. There was no evidence of muscle atrophy or ankylosis. Joint stability tests revealed no evidence of recurrent subluxation or persistent instability, ligament tear, or patellar instability. There was also no evidence of a meniscal condition or indication of any previous surgery. The Veteran reported using a knee brace on a regular basis. The Board has considered whether separate, compensable ratings are warranted under any other diagnostic codes. Upon evaluation of the evidence of record, Diagnostic Code 5256 is not applicable because the evidence does not show ankylosis, or the functional equivalent, of the left knee. There is no allegation to the contrary. As the Veteran had never undergone any surgery to remove his cartilage, Diagnostic Code 5259 is not applicable. Diagnostic Code 5258 provides that a 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion of the joint. As such symptoms have not been shown, a disability rating under this code is not warranted. Diagnostic Code 5262 is also not applicable for the left knee because the Veteran's left knee disability does not involve the impairment of the tibia or the fibula. There is no allegation to the contrary. There is no evidence of nonunion or malunion of the left knee. Furthermore, without a showing of genu recuvatum (acquired, traumatic, with weakness and insecurity in weight-bearing), a disability rating under Diagnostic Code 5263 is not warranted. There is no allegation to the contrary. The Board will now address whether the Veteran's increased rating claim is warranted based on limitation of motion. Under Diagnostic Code 5260, a rating in excess of 10 percent is warranted when the forward flexion in a knee is functionally limited to 30 degrees or less. Under Diagnostic Code 5261, a 10 percent disability rating is assigned when extension is limited to 10 degrees, and a 20 percent disability rating is assigned when extension is limited to 15 degrees. A 30 percent disability rating is assigned when extension is limited to 20 degrees, and a 40 percent disability rating is assigned when extension is limited to 30 degrees. Finally, a 50 percent disability rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § § 4.71a, Diagnostic Code 5261. The Court has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint's functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca, 8 Vet. App. 202. Additionally, in Mitchell, 25 Vet. App. 32, the Court explained that pursuant to 38 C.F.R. § §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § § 4.59; see also Correia, 28 Vet. App. 158. During the period on appeal, even though the Veteran did not demonstrate a range of motion limited to a compensable degree, he was assigned a 10 percent rating due to pain. While the Veteran disagrees, he has not submitted any evidence to support a rating higher than 10 percent. At his most recent examination in June 2021, the Veteran's forward flexion was functionally limited to 75 degrees and 0 degrees extension. There, the Veteran's forward flexion was initially to 105 degrees and 0 degrees extension. However, given his pain, his flexion was still only limited to 75 degrees and 0 degrees extension. He was able to complete a repetitive use test with at least three repetitions without resulting in additional loss of range of motion or functional loss. Even considering the Veteran's limited flexion at his April 2014 VA examination, where his flexion was only functionally limited to 45 degrees with 0 degrees extension (reduced from an initial 140 degrees of flexion) due to pain, such limitation warrants a 10 percent rating and not more. Next, to warrant a separate compensable rating for extension, the Veteran must show that his extension is functionally limited at 10 degrees. In this case, the Veteran's extension is most limited at 5 degrees and his muscle strength tests all revealed normal strength in his extension throughout the entire period on appeal. Therefore, a separate rating is not warranted for limited extension under Diagnostic Code 5261. The Board notes the Veteran's representative contends that the June 2021 examination is inadequate as the examiner did not consider the Veteran's lay statements and incorrectly noted the Veteran had not had left knee surgery despite documenting ORIF surgery in the diagnosis section of the examination. See November 2021 Appellate Brief. However, when the examination report is read in its entirety, the Board finds it clear the examiner was aware of the Veteran's left knee surgery and carefully considered the Veteran's statements about his pain and functional limitations. Turning now to the Veteran's separate rating for instability, the Board finds that a compensable disability rating of 10 percent is warranted for the period on appeal. The Veteran's representative contends the Veteran has a history of knee instability. As previously mentioned, the Board finds that a compensable rating under the revised Diagnostic Code 5257 is not warranted. Under the new criteria, a diagnosis of patellofemoral complex with recurrent instability must be shown. However, prior to February 7, 2021, 38 C.F.R. § 4.71a -Schedule of Ratings Musculoskeletal System under the DC 5257 provides for ratings based on recurrent subluxation or lateral instability from mild/slight to moderate to severe and respectively assigned a rating at either 10, 20, or 30 percent. The new revised 38 C.F.R. § 4.71a DC 5257 criteria effective from February 7, 2021, essentially, replaces these subjective terms (mild/slight, moderate, severe) with detailed descriptions of levels of impairment resulting from recurrent subluxation or instability or from patellar instability. The VA Schedule for Rating Disabilities prior to February 7, 2021, did not define the words "slight," "moderate," and "severe." Rather than applying a mechanical formula, the Board must evaluate all the evidence so that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of such terminology by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Because Diagnostic Code 5257 did not define the terms used, one possible source for such definitions would be the dictionary. Webster's II New College Dictionary defines "slight," as relevant here, "small in size, degree, or amount." Id. at 1038. The definitions for "moderate" include "of average or medium quantity, quality, or extent." Id. at 704. Finally, definitions for "severe" include "extremely intense." Id. at 1012. The Veteran's left knee disability is diagnosed as residuals of internal derangement and degenerative joint disease. It has not been shown by medical evidence that he has patellofemoral pain syndrome or any other condition indicative of patellofemoral complex or ligamentous instability under the new criteria. However, under the old criteria, while the medical evidence failed to show objective indication of any instability in the left knee, the Board finds the Veteran has credibly reported symptoms suggestive of slight instability. Despite his consistent reports of pain with use of the left knee, his examinations in December 2010, February 2013, April 2014, May 2019, September 2020, and June 2021 all reported no abnormalities pertaining to anterior, posterior, or lateral instability. The examiners all found no evidence of recurrent patellar subluxation or dislocation, ligamental tear, or patellar instability. In contrast, the Veteran reported subjective symptoms of slight instability. For example, in his December 2010 correspondence, he indicated that his left knee felt "rubbery," which made him feel at risk of falling. He even installed handicap railings in his shower to give him more stability and support. At his December 2010 VA examination, he complained of giving way sensations and stiffness in the left knee that limits his walking, running, climbing stairs, and squatting. In a November 2012 statement, he reported using a knee brace to help him with his pain. At his March 2019 and September 2020 VA examinations, the Veteran demonstrated both pain and crepitus that effects his movement. Then, in June 2021, he continued to report the same symptoms, with popping sensations that gives way, requiring a brace, especially at work. The Board finds that the Veteran's subjective reports are sufficient to establish slight instability of the left knee. He is competent to report that he experiences sensation of his left knee giving way as this is within the realm of his personal perception. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). More recently, the Court in English v. Wilkie, 30 Vet. App. 347, 353 (2018), found that the Veteran's lay evidence of knee instability is generally competent. The Board is cognizant that objective medical evidence is not categorically more probative than lay evidence when it comes to determining the degree of left knee instability, if any, the Veteran has experienced during the appellate period. Collectively, the Board finds that the Veteran's report of the symptoms corroborate instability to a slight or small degree. However, his statements alone, do not describe a moderate or extremely intense degree of instability under the 20 or 30 percent rating criteria. While he is competent to report symptoms capable of lay observation, he is not competent to consider complex medical questions regarding the nature and severity of his symptoms or identify a specific level of disability according to the applicable Diagnostic Codes. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In summation, while the Veteran has not demonstrated a higher rating under limited motion, a separate disability rating of 10 percent is warranted for instability of the left knee. Service Connection To establish service connection on a direct basis the following elements must be satisfied: (1) the existence of 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 disease or injury incurred or aggravated during service (the medical "nexus" requirement). See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). Service connection may be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Certain chronic diseases, such as arthritis, which are manifested to a compensable degree within one year of discharge from active duty, shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such diseases during the period of service. See 38 U.S.C. §§ 1101 (3), 1112; 38 C.F.R. §§ 3.307 (a)(3), 3.309; Fountain v. McDonald, 27 Vet. App. at 263-64. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, if a chronic disease listed at 38 U.S.C. § 1101 (3) and 38 C.F.R. § 3.309 (a) is noted during service or the presumptive period, but not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In other words, for certain chronic diseases, the Veteran can establish service connection by a showing of "continuity of symptomatology." Fountain v. McDonald, 27 Vet. App. at 263; Walker v. Shinseki, supra. This requires the Veteran to show (1) a condition "noted" during service, (2) evidence of post-service continuity of the same symptoms, and (3) medical or lay evidence establishing a nexus, or link, between the current disability and the post-service symptoms. Fountain v. McDonald, 27 Vet. App. at 263-64. It is the Veteran's contention that he developed a bilateral ankle condition as a result of his service-connected left knee condition. Through his representative, the Veteran asserted that because of his left knee disability, it caused favoring of the joint, creating stress on other joints in the lower extremity. Specifically, the ankles bear the brunt of extra stress during ambulation in general, but particularly during the rigor of military training. See April 2021 Appellate Brief. Based on a September 2012 VA examination, it was noted that the Veteran had a left ankle strain, but not the right. He did not report any specific injury, but rather a gradual onset on pain, which is made worse by prolonged walking and standing. The examiner found that it was less likely than not that the Veteran's left ankle disorder is related to a service-connected disability. He indicated that based on the physical findings, it is possible that problems in the knee could cause problems in the hip on the opposite side. However, the literature does not support the theory that dysfunction in one joint cause compensatory dysfunction in joints on the same side. In his November 2012 statement, the Veteran indicated that he uses a knee brace and ice to alleviate his symptoms. Walking on his left leg could cause pain from his back down to his leg and toes. While changing his walk helps, it affects his ankle. See November 2012 VA 21-4138 Statement in Support of Claim. The Veteran was reevaluated at a February 2013 VA examination. There, it was noted that he had a right ankle strain but no mention of a left ankle strain. He did however, reported weakened movement and pain on movement with the left ankle. He also demonstrated a slight reduction in muscle strength scoring a four out of five in ankle plantar flexion and ankle dorsiflexion on the left side. Therefore, despite the lack of a left ankle diagnosis by the February 2013 VA examiner, there is sufficient evidence that the Veteran has a bilateral ankle disorder. In conclusion, the VA examiner found that it is less likely than not that the Veteran's ankle disability is related to service. He explained that a review of the claims filed only showed one complaint of a low ankle pain and swelling in July 1991. However, there were no subsequent complaints after that date, which suggest that the ankle injury healed and did not become a chronic problem. The examiner also found that it is less likely than not that the Veteran's ankle disability this caused by a service-connected condition. He explained that the review of medical literature does not support the theory that the distal function in one joint either causes or aggravates the dysfunction in another. In a July 2014 correspondence, the Veteran asserted that his knee pain affected his walk, which affects his ankles as well as his back and hips. Within the past three years, he had to sell his motorcycle and car because of the numbness in his legs. When the matter came to the Board in July 2018, it was remanded for a new VA examination as it found that the September 2012 examination was inadequate. While the examiner found that the problems in a knee could cause problems in the hip on the opposite side but not on the same side, he did not address the Veteran's claimed right knee disability or right ankle disorder. Moreover, he did not provide an adequate reasoning why the Veteran's bilateral ankle condition is less likely caused or aggravated by his service-connected back condition. A new VA examination was conducted in March 2019. There, it was noted that the Veteran has a degenerative joint disease in the right ankle and an ankle strain on the left side. He reported flare ups on both ankles which occur approximately twice a week. He demonstrated an abnormal range of motion in both ankles. In conclusion, the examiner found insufficient medical evidence to support that the Veteran's left and right ankle condition is secondarily caused by his service-connected left knee internal derangement. In his rationale, the examiner indicated that the Veteran had only mild degenerative joint disease of the right ankle and a mild strain in the left ankle. A medical opinion addendum was issued in May 2020 in which the examiner found that the Veteran's bilateral ankle condition is less likely aggravated beyond its natural progression by the Veteran's service-connected left knee internal derangement as there was insufficient medical evidence to support as such. In his rationale, the examiner noted that the Veteran's separation physical examination in November 1992 was unremarkable for any orthopedic musculoskeletal abnormalities of the left and right bilateral ankle. The mild right ankle degenerative joint disease can be typically associated with the development and progression of age. The left ankle strain can be associated with acute or repetitive traumatic injuries to the ankle. However, there is no medical documentation of any injury to the left ankle, associated or caused by the left knee internal derangement post military service. Furthermore, typically, a strain of the ankle joint is associated with direct acute or repetitive trauma to that angle and is therefore, unlikely due to or aggravated by the Veteran's left knee condition. Based upon the most recent evaluations of the knee, there was no instability issues. Therefore, it is less likely that the Veteran's bilateral ankle condition resulted from his service-connected left knee condition or his military service. The Board notes that during the period on appeal, the Veteran's service connection claim for a right knee disability was granted. In an October 2020 rating decision, the AOJ assigned a 10 percent rating upon the grant of service connection based on an October 2020 medical opinion. The examiner found that the Veteran's right knee condition worsened beyond its natural progression due to his service-connected left knee disability. In his rationale, he indicated that the residuals of internal derangement of the left knee caused significant favoring and placement of additional weight on to the right knee. Thus, actions such as walking, stair climbing, stooping, bending, causes additional physical stress on the right knee, which would cause his right knee condition to progress beyond its natural progression. The Board notes that the October 2020 medical opinion, now suggests that problems in one joint, could cause problems in another. In the April 2021 Appellate Brief, the Veteran argued that while the May 2020 VA examiner indicated that the type of ankle condition sustained by the Veteran would result from repetitive trauma, his military training, which include two-mile runs and regular marches could have caused repetitive trauma to the ankles, especially when taking into account the natural favoring of at least one ankle. When the matter came to the Board in May 2021, it was remanded again for a new medical opinion. It found that the medical opinions of the record offered contradictory conclusions. The May 2019 and May 2020 examiner concluded that a "typical strain of the ankle joint is associated with direct acute or repetitive trauma to that ankle and is unlikely due to or aggravated by the left knee disability." However, that same examiner issued an opinion in October 2020, concluding that the Veteran's left knee disability "would cause significant favoring and placement of additional weight bearing on the right knee, and asymmetry with walking, climbing, stooping, and bending, resulting over time with additional physical stress load on the right knee and progression of right knee strain beyond natural progression." Such conclusion hints at a causal connection between joints of the lower extremities as stress on the knee may cause physical stress on the ankle. Additionally, the Board also noted that the Veteran asserted that pain from his lumbar spine and knees have altered his gait mechanics severe enough to cause his current bilateral ankle disorder. Therefore, given the contradicting nature of the opinions, the Board remanded to obtain a new medical opinion. A new medical opinion was obtained in June 2021. The examiner noted that after service, the Veteran worked as a long-haul truck driver from 1994 to 2001. He then worked for a property management company as a building engineering/building maintenance since 2007. He also drove a pickup truck for a few years and later cleaned parking lots. After his incarceration between 2003 and 2006, he remained active with exercise using free weights, walking, calisthenics, but not high impact exercise. His job duties include everything from changing lightbulbs, going up and down the stairs, working under the sink, changing ceiling tiles and doing paperwork behind a sit/stand desk. Additionally, he manages three different properties and tries to limit his heavy lifting by using carts and dollies. The Veteran asserted that his ankles began hurting approximately 15 to 20 years earlier, which started with sensations of clicking, cracking, with stiffness. He denied any specific injuries to his ankles and that his pain began gradually over the years. Upon review of the Veteran's claims file, the VA examiner found that he has achilles enthesophyte in both left and right ankle and mild degenerative joint disease in the right ankle, only. The examiner highlighted the Veteran's report that he had ankle pain since service. After his separation, he complained of flare-ups twice a week in which he would have difficulty dorsiflexing his ankles past 5 degrees. He indicated that his ankle began hurting 15 to 20 years ago, with sensations of clicking, cracking, with stiffness. There was been a gradual onset in pain. He denied any specific injury to either ankle. He reported pain in the front of his ankles and feet with occasional pain behind his medial malleolus. In conclusion, the examiner first found that the Veteran's bilateral ankle disorder is less likely aggravated beyond its natural progression by his service-connected knee disabilities. In her rationale, the examiner indicated that medical literature does not support the theory that dysfunction in one joint causes dysfunction in another. Knee problems causing a limp of low magnitude are unlikely to create load transmission of any significant magnitude to cause additional stress on the ankles. An injury to one lower extremity would not have any significant impact on the ankles unless the injury resulted in major muscle or nerve damage causing partial or complete paralysis of the damaged leg, and/or a significant limb length discrepancy. In this case, there is no clear evidence to suggest that an injury to one lower extremity would have any significant impact on the opposite uninjured limb unless the injury resulted in major muscle or nerve damage, causing partial or complete paralysis of the damaged leg, and/or a significant limb length discrepancy. While it may seem logical that maneuvers designed to lessen the load on one leg would increase that on the other, there is no evidence to support this. Gait studies on patients who had a paralytic and short-leg limp from old poliomyelitis confirmed that while the force transmitted on the affected leg was reduced, the force transmitted onto the opposite leg was the same as in normal (unaffected) individuals. The findings were similar in patients with an antalgic gait resulting from arthritis. A review of the Veteran's records is silent for any abnormal gait patterns until 2008. He had fractured his right proximal tibia in a motorcycle accident. The physical therapist observed a mild toe out pattern. None of the other records note any abnormal gait pattern and there are no records to support a limp. Upon physical examination, the Veteran did not demonstrate antalgic gait pattern or limp. A mild toe out gait was noted on the right side. Most recent ankle imagine showed a diagnosis of achilles enthesophyte and mild degenerative changes. The cause of Achilles tendon enthesopathy is chronic traction of the Achilles tendon on the calcaneus due to contracted or shortened calf muscles and overuse. It is not related to the service-connected knee condition. The degenerative changes of the ankles are more likely due to changes associated with the normal process of aging. Overtime, degenerative changes would be expected in a person who has participated in life's recreational and work physical activities. The Veteran has always worked in a physically demanding job. An increased BMI would also cause further stresses that would encourage osteoarthritis. There is no objective evidence to support that there has been an aggravation of the claimed bilateral ankle condition. His ankle condition has not made worsened beyond the natural progression. There is no objective evidence in the Veteran's examination, medical records, or medical literature suggesting a causative link between the Veteran's knee conditions and his current bilateral ankle condition, as they are two separate conditions. Therefore, it is less likely than not that the Veteran's claimed bilateral ankle disorder is proximately due to or aggravated beyond its natural progression by the service-connected left knee or the right knee disability, to include overcompensation and altered body mechanics. Second, the VA examiner concluded that it is less likely than not that the Veteran's bilateral ankle condition is secondary to the Veteran's lumbar spine disability or left lower extremity sciatica. In her rationale, the examiner explained that back and leg problems causing a limp of low magnitude and are unlikely to create load transmission of any significant magnitude to cause additional stress on the ankles. The injury would not have any significant impact of the ankles unless the injury resulted in major muscle or nerve damage causing partial or complete paralysis of the damaged leg, and/or a significant limb length discrepancy. Rather, the Veteran's bilateral ankle condition is more likely due to the overuse and changes associated with the normal process of aging. Overtime, degenerative changes would be expected in a person who has participated in life's recreational and work physical activities. An increased BMI would cause further stresses which would encourage osteoarthritis. His records did not report any abnormal gait until 2008. He had fractured his right proximal tibia in a motorcycle accident. The physical therapist obtained a mild toe out of pattern. However, his records did not report any abnormal gait or limp as a result. A mild toe out gait was noted on the right side. There was also no objective evidence to support that there has been an aggravation of a claimed "bilateral ankle condition," beyond its natural progression. The record does not suggest any causative link between the Veteran's lumbar spine condition and his current bilateral ankle condition. These two conditions are separate anatomical conditions. Therefore, it is less likely than not that the claimed bilateral ankle disorder is proximately due to or aggravated beyond its natural progression by the lumbar spine and/or left lower extremity sciatica disabilities to include overcompensation and altered body mechanics. In reviewing the record, the Board finds that service connection for a left and a right ankle disorder is not warranted. First, the Board finds that service connection on a direct basis was not established in this case. He has asserted that his bilateral ankle condition was caused by the repetitive traumatic injuries from two-mile runs and regular marches in service. The Veteran's service treatment records noted pain in the left ankle and foot in July 1991. Swelling, redness, and tenderness was reported. He was treated accordingly, and subsequent treatment records did not document any follow-up complaints relating to the ankles. He was seen for other injuries and issues but did not return for an ankle complaint. His report of medical examination in November 1992 did not report any clinical abnormalities of his lower extremities. The Veteran did not demonstrate a left or right ankle condition until several years after service. While not dispositive, this passage of time weighs against the Veteran's claim. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Based on his September 2012 VA examination, he was diagnosed with a left ankle strain, first detected in 2010. A right ankle strain was noted to have been diagnosed in 2009. See February 2013 VA examination report. The Veteran has not submitted any positive medical evidence to support his claim that his bilateral ankle condition resulted from service. Moreover, the February 2013 VA examiner found that it was less likely than not that the Veteran's ankle disability resulted from service. While that examination report was found inadequate by the Board in July 2018, the inadequacy pertained only to the examiner's opinion on secondary theory of entitlement. Therefore, the Board's find the February 2013 opinion on direct service connection probative, and service connection on a direct basis has not been established. The Board has also considered service connection through a continuity of symptomatology for a chronic ankle condition. The Veteran suffered a left ankle injury in service. However, as previously noted, subsequent in-service treatment records failed to establish a continuity of symptoms. There were no records supporting a diagnosis in-service or within one year of separation. Neither was there any evidence that the condition became compensable within one year of separation. Moreover, the Veteran reported his ankle pain 15-20 years ago, which is many years after his active service. As such, there is no presumption of service connection. Finally, the evidence is against finding in favor of service connection on a secondary basis. The Veteran asserted that he developed a bilateral ankle condition as a result of his service-connected knee condition. Specifically, his knee disabilities have caused him to shift his weight, altering his gait. The change in his body mechanics have ultimately resulted in a chronic ankle condition. He reported that his pain gradually increased over the years. Various physical examinations have clearly confirmed a present diagnosis of a left and a right ankle disability. However, medical evidence has not established a positive nexus between the Veteran's service-connected knee disabilities and his bilateral ankle condition. The most probative medical opinion of record, namely the June 2021 opinion, found that it was less likely than not that the Veteran's bilateral ankle disabilities was caused or aggravated beyond its natural progression by his service-connected knee disabilities. The examiner explained that knee problems causing a limp of low magnitude are unlikely to create load transmission of any significant magnitude to cause additional stress on the ankles. An injury to one lower extremity would not have any significant impact on the ankles unless the injury resulted in major muscle or nerve damage causing partial or complete paralysis of the damaged leg, and/or a significant limb length discrepancy, which has not been shown in this case. The Veteran's medical records does not show that he has such an abnormal gait pattern that would have resulted in achilles enthesophyte and mild degenerative changes of the ankle, even considering the Veteran's reported overcompensation and altered body mechanics. The June 2021 VA examiner also concluded that it was less likely than not that the Veteran's bilateral ankle condition is caused or aggravated beyond its natural progression as a result of his service-connected low back disability. Similar to the knee disabilities, the examiner explained that the low back disability or leg problems causing a limp of low magnitude are unlikely to create load transmission of any significant magnitude to cause additional stress on the ankles. The record has not shown that the Veteran has a gait so severe or partial paralysis that would have resulted in an ankle disability. In fact, the Veteran's lumbar spine condition and his ankle disabilities are separate disabilities. Additionally, the Board notes that post service, the Veteran engaged in physically demanding labor. He worked as a long-haul truck driver, building engineer and maintenance. He also remained physically active and exercised with weights. The June 2021 VA examiner suggested that the Veteran's high BMI and physically demanding jobs may have caused aggravation on his bilateral ankle and would likely worsen over time, resulting in his current disability. Therefore, service connection is not established for the Veteran's left and right ankle disabilities. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b) and 38 C.F.R. § 3.102. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Yeh, Associate 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.