Citation Nr: 21005506 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 13-03 166A DATE: February 1, 2021 ORDER Entitlement to special monthly pension based on the need for aid and attendance or housebound status is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a left knee disability is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran is already in receipt of VA compensation benefits that are of greater value than the claimed special monthly pension benefits. 2. The Veteran did not exhibit a low back disability in service; degenerative joint disease of the low back did not manifest to a compensable degree within one year after discharge from service; and such disability is not otherwise shown to be associated with service, to include as superimposed over a congenital defect.  3. The Veteran did not exhibit a left knee disability in service; degenerative joint disease of the left knee did not manifest to a compensable degree within one year after discharge from service; and such disability is not otherwise shown to be associated with service.  CONCLUSIONS OF LAW 1. The criteria for entitlement to special monthly pension based on the need for aid and attendance or housebound status have not been met. 38 U.S.C. § 5304; 38 C.F.R. § 3.700. 2. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a), 4.9.  3. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a).  REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1987 to July 1991. This matter comes before the Board on appeal from a December 2010 Regional Office (RO) rating decision. In June 2016, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Special Monthly Pension 1. Entitlement to special monthly pension based on the need for aid and attendance or housebound status is denied. The governing laws and regulations have long held that a veteran may not receive concurrent payments of compensation and pension benefits and require a veteran to elect to receive one benefit or the other. 38 U.S.C. § 5304; 38 C.F.R. § 3.700. In the case at hand, the Veteran is in receipt of compensation benefits for an acquired psychiatric disability, a left hip disability, a right hip disability, and tinnitus. His combined ratings during the period that is contemplated by this appeal are 100 percent (prior to January 1, 2012) and 70 percent (on and after January 1, 2012). His VA compensation benefits are of greater value than the special monthly pension benefit to which the Veteran has claimed entitlement. Therefore, the Board finds that entitlement to special monthly pension based on the need for aid and attendance or housebound status is not warranted. Service Connection Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for listed chronic diseases, such as arthritis, if such were shown as chronic in service; manifested to a compensable degree within a presumptive period (usually one year) after separation from service; or were noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Congenital or developmental defects are not diseases or injuries, and therefore they may not be service-connected. 38 C.F.R. § 3.303(c), 4.9; see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). However, if a disease or injury is superimposed over the congenital or developmental defect during service, service connection may be warranted for the resultant disability. VAOPGCPREC 82-90 (July 18, 1990). 2. Entitlement to service connection for a low back disability is denied. This claim has arisen from the Veteran’s corroborated account of having been at the scene of a terrorist car bomb explosion in Naples, Italy, on April 14, 1988. (See August 2009 Veteran statement; service personnel records; internet articles and research corroborating occurrence of the attack.) The Veteran has reported that the blast threw him into a concrete wall and that he suffered a back injury at that time. (See August 2009 and August 2010 statements.) The Veteran’s service treatment records reflect that his spine was clinically normal at the times of a September 1986 enlistment examination, an undated OSS examination, and a May 1991 separation examination. He denied any history of, or current, recurrent back pain on an August 1986 applicant medical prescreening form, a September 1986 enlistment medical history report, an undated OSS medical history report, and a May 1991 separation medical history report. Otherwise, the Veteran’s service treatment records reflect that he neither complained of nor sought treatment for symptoms related to his back. A May 2000 private medical record notes that the Veteran “has some spasms of the neck muscles and lower back.” An October 2003 private medical record notes that the Veteran “has been having a severe, throbbing back pain radiat[ing] to the lower extremities particularly to the left lower extremity. He said that he has had low-back pain on and off.” A November 2003 MRI report notes findings including multilevel degenerative disc disease. Another November 2003 private medical record notes that the Veteran “is still having this back pain.” It was noted that the “MRI did show evidence of herniated discs at multiple levels particularly encroachment towards the left.” An impression of lumbar radiculopathy at L4-L5, L5-S1, was given. A January 2004 private chiropractor treatment record notes that the Veteran has “pain in the upper and lower back occurring intermittently at a moderate intensity.” The Veteran noted on a form he filled out for a private chiropractor’s office in January 2004 that his low back pain symptoms had appeared seven years earlier. A February 2004 private chiropractor’s record notes that the Veteran reported that his low back froze up two days earlier and he was unable to do anything. A March 2004 private chiropractor’s record notes that the Veteran reported “soreness in low back from doing a lot of yard work.” A May 2005 private chiropractor treatment record notes that the Veteran has “soreness and spasms of the neck and lower back occurring constantly at a moderate intensity.” A December 2005 private chiropractor treatment record notes that the Veteran has “spasms and pain of the neck, upper and lower back occurring constantly at a severe to excruciating intensity.” A February 2006 private chiropractor treatment record notes that the Veteran has “pain in the neck, lower back occurring constantly at a moderate intensity.” A February 2007 private chiropractor treatment record notes that the Veteran has “pain, discomfort, spasms, tightness in the lower back, legs occurring constantly at a severe intensity.” An April 2007 private medical record notes that the Veteran “fell and reinjured his back last week.” A June 2007 private medical record notes that the Veteran sought treatment after he “slipped on the floor and dislocated his left knee and strained his lower back.” An October 2008 private MRI report notes an impression of “Multilevel degenerative disc disease with disc bulging, anular tears at multiple levels and associated neural foraminal narrowing. Central canal stenosis seen most prominently at L4-L5.” A November 2008 private medical record notes that an MRI of the lumbar spine three years earlier was normal. A November 2008 private medical record notes that the Veteran “states he has had low back pain for the last eight years. It has been worsening over the last three years, to the point it is constant.” The Veteran “states approximately two years ago he had an episode where he had sudden severe onset of low back pain and was unable to move his lower body.” A December 2008 private MRI report notes that “Lumbar spondylosis is present, particularly at L4-L5.” A December 2008 private medical record notes that the Veteran is status post lumbar laminectomy. The December 2008 private operative report notes that “This is a case of a 39-year-old gentleman with chronic back pain who, upon workup, was found to have a tumor on his MRI of the lumbar spine.” A January 2009 private medical record notes that the Veteran “underwent an L2-L3 laminectomy and gross total resection of his filum terminale tumor.” An April 2009 private medical record notes that the Veteran “states that on 4/16 he threw his back out doing his yard.” A December 2009 private orthopedic record notes that the Veteran has “chronic back pain history x 20 years – with multiple disc bulges and spinal tumor removal 2008.” The record contains an August 2009 psychosocial assessment report noting that the Veteran “was involved in a car bombing while enlisted in the Navy in Naples, Italy when he was 19 years old. He stated that his spine was compressed and he ended up with bulging discs. His lower back has many difficulties at the present time due to the bombing.” It was later noted that the Veteran “states that he is in constant back pain mostly from his Navy injury.” In August 2010, the Veteran told a VA psychiatric examiner that he had injured his back in the blast. The Veteran noted in an August 2010 statement that, in Spring 2009, he had informed his neurologist that he had injured his back during a bomb blast in service. He stated that he was told by his Navy doctors that his hip pain was part of his back pain. The Veteran noted in an August 2014 statement that he has submitted opinions from a VA orthopedic surgeon and neurologist who have treated the Veteran. He noted that “Both VA physicians agree that the injuries I sustained during my time in the Navy resulted in ‘cause and effect’ and have a direct and substantial impact on my health today.” The Board has reviewed these opinions but notes that they only opine as to his hip disabilities, not his back disability. He described the in-service explosion in detail at his June 2016 Board hearing. He stated that he started feeling sore a few days after the explosion but did not seek treatment for symptoms related to this blast. He also stated that he continued to perform all of his duties, including running and working out to stay in shape. (See Board hearing transcript, pages 9-10.) The Veteran underwent a VA back examination October 2018. At this examination, he reported that “he started getting low back pain since approx. 1988/89. He states he was not seen for the back while in service.” Following review of the record and interview and examination of the Veteran, the VA examiner opined that the Veteran’s back disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In the rationale, the physician’s assistant noted that the Veteran’s service treatment records “had no documentation for any back abnormality.” The VA examiner’s own examination of the Veteran’s back revealed degenerative disc disease (DDD) L2 to S1 with moderate scoliosis and noted that “The most likely cause of this Veteran’s DDD L2-S1 is his scoliosis which is a congenital condition.” The examiner also noted that “This Veteran also had a tumor removed from his lumbar spine after service which can also be a contributing factor.” The examiner stated that “Although this veteran states he was injured in a car bomb, his current diagnosis of DDD L2 to S1 with moderate scoliosis has no cause or relationship to the car bomb or service.” A January 2019 private medical record notes that the Veteran’s “back pain has been there for the past 30 years and he has failed medical management including injection and physical therapy.” It also notes that “he does have lumbar scoliosis with apex at the level of L2-3.” A June 2019 private medical record notes that the Veteran “describes a surgery done in 2007 for a benign spinal tumor that was incidentally found after car explosion.” The Veteran again underwent a VA examination in September 2020. This examination was conducted by a physiatrist. The Veteran stated that “pain in back and left knee started after he was thrown against a desk during a car [bombing] in 1988 while attending an USO ship party in Naples, Italy.” It was again noted that the Veteran “was not treated while in service and was able to complete his service without any problems. However, his pain got worse over years.” Based on review of the record and interview and examination of the Veteran, the VA examiner diagnosed degenerative disc disease; degenerative scoliosis, status/post fusion and instrumentation with residuals; and L2-3 laminectomy and Ependymoma removal. The examiner opined that the Veteran’s low back disabilities are not incurred in or caused during active service, including the April 1988 car bomb. The examiner stated that it is less likely as not that his current low back disabilities are related to service. The examiner noted that: All available [service treatment records] and [the claims file] are completely silent for any kind of back condition at any time during service or at any time until 11/2008 when he was seen for progressive back pain “for the last eight years” and was found with “L2-L3 tumor” and DDD of lumbar spine/“disc bulges at L3-L4, L4-L5 and L5-S1” and subsequently underwent “L2-L3 laminectomy and tumor resection.” The examiner stated that the Veteran’s lumbar spine disabilities are not caused by service, to include the car bombing. In the rationale, the examiner cited “lack of any documented injury/trauma to lumbar spine while in service and lack of the chronicity of back problem following service until years after separation.” The examiner noted that such an injury (from a car bomb explosion) “usually will cause acute or subacute (days or weeks) pain/or symptoms in lumbar spine. Therefore, the complete absence of medical records of any trauma/injury and associated symptoms in lumbar spine while in service is medically significant.” The examiner further stated that “The pathology/disease process associated with the Veteran’s back is not consistent with the mechanism of injury (car bomb injury in 1988) claimed by the Veteran.” The examiner then noted that “The pathology/disease process associated with the Veteran’s lumbar spine (DDD/DJD) [degenerative joint disease] is consistent with the mechanism of aging process which is well established and supported by peer reviewed medical literatures.” The September 2020 VA examiner included multiple citations to pertinent medical literature to support this opinion. The Board notes that its November 2019 remand directed that “This examination must be conducted by an orthopedic surgeon.” However, this examination was conducted by a physiatrist. The Board notes that the record contains significant evidence that the RO attempted to fulfill this direction. However, they were unable to do so, as the examination provider “do[es] not have the request[ed] specialist available to examine the veteran,” and the initial request was cancelled. The examination schedulers then clarified that an examination, rather than just an opinion, was required. They informed the RO that: We don’t have an Orthopedist in Comp & Pen that can do an exam/opinion for the knee/low back but we do have PM&R physicians (Physiatrist) who have completed training in the specialty of Physical Medicine and Rehabilitation (PM&R), and they complete Comp & Pen exams on a wide variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons. If that is acceptable you can submit and notate that an exam/opinion by a Physiatrist is acceptable. The RO notified the schedulers that examination by a physiatrist was acceptable and requested that the examinations be rescheduled. The Board finds that the RO undertook all appropriate measures to attempt to fully comply with the Board’s instruction. However, complete compliance was not possible, and the RO fulfilled the Board’s instruction as best as possible under the circumstances. The Board has reviewed the physiatrist’s qualifications, as laid out by the examination scheduler, and finds that the physiatrist was properly qualified to conduct the requested examination and provide the requested opinion. See Cox v. Nicholson, 20 Vet. App. 563 (2007). The Board thus finds that the RO substantially complied with the Board’s remand instruction and concurs with the RO’s decision to proceed with having a physiatrist conduct the examination and render the requested opinion. The resulting September 2020 opinion is based on review of the record and on interview and examination of the Veteran. The opinion contains a complete rationale that includes discussion of the facts of the Veteran’s case and pertinent medical principles. The Board notes that this opinion does contain an error of fact in that the examiner stated that the service treatment records and post-service records “are completely silent for any kind of back condition at any time during service or at any time until 11/2008.” The Board notes, however, that the claims file contains records from as early as May 2000 reflecting back complaints, and that there are multiple records between May 2000 and November 2008 reflecting complaints of and treatment for his low back. For example, a November 2003 MRI report notes findings including multilevel degenerative disc disease. The Board has considered whether this factual error renders the entire medical opinion inadequate for adjudication purposes but finds that it does not. The Board notes that the bombing occurred in April 1988 and that the Veteran separated from service in July 1991. The examiner’s opinion is based, in part, on the fact that the Veteran did not manifest a low back disability for many years following his separation from service. The Board notes that the Veteran had separated from service nine years prior to the earliest low back treatment of record. The Board finds that a nine-year gap between service and the earliest notation of low back complaints is not materially different from a 17-year gap for purposes of this opinion, as both represent a significant gap between the end of service and the initial reports of back symptoms. The opinion relies on the factual finding that there was no evidence of back abnormality during service. Its rationale discussing the nature of the Veteran’s current low back disability is not impacted by a misestimate of how many years following service a chronic low back disability is shown. The Board further notes that the VA examiner acknowledged that the November 2008 medical record notes that the Veteran reported an eight-year history of low back symptoms. The examiner also included a portion of the May 2000 private medical record noting that the Veteran “has some spasms of the neck muscles and lower back.” The examiner was thus aware that the Veteran had reported having had back problems as early as 2000. In addition, as noted above, the examiner’s rationale features an assessment that the type of disability from which the Veteran currently suffers is not consistent with the claimed mechanism of injury. This assessment would not be affected by an estimate that the disability first manifested 17 years after service rather than nine years. In view of the above, the Board finds that the September 2020 VA examiner’s opinion remains highly probative to the case at hand, as the examiner has provided a rationale that is consistent with pertinent medical principles. The VA examiner set forth a medical reason to reject the proposition that the Veteran’s exposure to a bomb explosion left chronic back residuals as such an injury would have required medical attention. The Veteran’s assertion that he had back pain in service and ever since service is not credible. With respect to the other evidence of record, the Board notes that there are medical records in the claims file that suggest a relationship between the in-service bombing and a current back disability. As noted above, the record contains an August 2009 psychosocial assessment report noting that the Veteran “was involved in a car bombing while enlisted in the Navy in Naples, Italy when he was 19 years old. He stated that his spine was compressed and he ended up with bulging discs. His lower back has many difficulties at the present time due to the bombing.” In addition, he noted in an August 2010 statement that in Spring 2009, he informed his neurologist that he had injured his back during a bomb blast in service. He stated that he was told by his Navy doctors that his hip pain was part of his back pain. Furthermore, a January 2019 private medical record notes that the Veteran’s “back pain has been there for the past 30 years.” The Board finds that these records do not constitute probative medical evidence of a link between the current back disability and service as they are mere transcriptions of the Veteran’s report of his own history. They do not purport to be medical opinions from the medical providers who transcribed this information. Therefore, the Board finds that this evidence does not constitute probative medical opinion in support of the Veteran’s claim. As noted above, the Veteran had also noted in an August 2010 statement that he was told by his Navy doctors that his hip pain was part of his back pain. The Board notes, however, that the Veteran’s service treatment records do not reflect any complaints of back pain, regardless of the cause. The Board further notes that no current medical evidence has attributed a current back disability to the same cause as the cause of his hip disabilities. The Board therefore finds that entitlement to service connection for a low back disability cannot be granted based on this statement. As noted above, the Veteran has been found to have scoliosis, which is a congenital defect. Even though service connection cannot be granted for a congenital defect, if a disease or injury is superimposed over the congenital or developmental defect during service, service connection may be warranted for the resultant disability. VAOPGCPREC 82-90 (July 18, 1990). In the case at hand, however, the competent medical evidence of record establishes that the Veteran does not currently have an additional back disability attributable to service. Therefore, service connection based on injury superimposed over his scoliosis is not warranted. The only remaining contrary opinion comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. The Board notes that the Veteran had a spinal cord tumor excised in December 2008. The Board notes that the Veteran’s arguments to VA have not involved contentions that this tumor was related to service. In addition, even though a June 2019 private medical record notes that the Veteran “describes a surgery done in 2007 for a benign spinal tumor that was incidentally found after car explosion,” the Board notes that the contemporaneous evidence of record from the time of the tumor excision surgery reflects that the tumor was found shortly before the surgery itself. Moreover, this tumor was excised prior to the date of the Veteran’s claim and there are no suggestions of residuals or recurrence; thus there is no “current disability” for purposes of establishing service connection. Based on the above, the Board finds that entitlement to service connection for the Veteran’s excised spinal tumor is not warranted. Finally, there is no persuasive medical evidence or persuasive credible lay evidence that the Veteran's claimed disorder manifested to a compensable degree within a year of his separation from service or had its onset in service and continued ever since service. Therefore, service connection based on presumptive service connection for a chronic disease or based on a theory of continuity of symptomatology is not warranted. Accordingly, the Board must find that entitlement to service connection for a low back disability is not warranted on a direct basis, as a disability superimposed over a congenital defect, or on a presumptive basis based on chronic disability. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 3. Entitlement to service connection for a left knee disability is denied. The Veteran’s left knee disability claim has arisen from his corroborated account of having been at the scene of a terrorist car bomb explosion in Naples, Italy, on April 14, 1988. (See August 2009 Veteran statement; service personnel records; internet articles and research corroborating occurrence of the attack.) The Veteran has reported that the blast threw him into a concrete wall. (See August 2009 statement.) He described this incident in detail at his Board hearing. He stated that he started feeling sore a few days after the explosion but did not seek treatment for symptoms related to this blast. He also stated that he continued to perform all of his duties, including running and working out to stay in shape. (See Board hearing transcript, pages 9-10.) The Veteran’s service treatment records reflect that his lower extremities were clinically normal at the times of a September 1986 enlistment examination, an undated OSS examination, and a May 1991 separation examination. He denied any history of, or current, painful or trick joints or loss of movement in any joint on an August 1986 applicant medical prescreening form. He denied any history of, or current, trick or locked knee on a September 1986 medical history report and an undated OSS medical history report. He endorsed a history of, or current, trick or locked knee on his May 1991 separation medical history report. He did not identify whether this history involved his left or right knee or otherwise describe the nature of these complaints. Otherwise, the Veteran’s service treatment records reflect that he neither complained of nor sought treatment for symptoms related to his left knee. A June 2007 private medical record notes that the Veteran sought treatment after he “slipped on the floor and dislocated his left knee and strained his lower back.” A June 2007 private radiologist’s MRI report reflects that the Veteran sought treatment for his knee. It notes an impression of “Edema identified along the medial facet of the patella and lateral femoral condyle compatible with an impaction injury from lateral patellar dislocation.” It also notes that, “Given the location of the edema, this patient may have had a recent lateral patellar dislocation. Clinical correlation is recommended.” A July 2007 private medical record notes that the Veteran “had knee surgery and his knee pain has improved some.” An October 2007 private medical record notes that the Veteran had surgery on his knee. A December 2008 private medical record notes that “Apparently about three months ago he started having a problem with his knee.” A March 2010 private medical record notes that the Veteran had left knee surgery in 2007. The Veteran noted in an August 2014 statement that he has submitted opinions from a VA orthopedic surgeon and neurologist who have treated him. He noted that “Both VA physicians agree that the injuries I sustained during my time in the Navy resulted in ‘cause and effect’ and have a direct and substantial impact on my health today.” The Board has reviewed these opinions but notes that they only opine as to his hip disabilities, not his left knee disability. The Veteran underwent a VA knee and lower leg conditions examination in connection with this claim in October 2018. It notes that the Veteran “states that he started having left knee clicking x 20 yrs. He states he injured his left knee from a car bomb 1988 but was[] not seen for the left knee at that time. He states he lost 45lbs and has some improvement.” Following review of the record and interview and examination of the Veteran, the VA examiner opined that the Veteran’s left knee disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In the rationale, the physician’s assistant noted the Veteran’s service treatment records “had no documentation for any knee problems.” The physician’s assistant further noted that “Examination today revealed Left knee patellofemoral syndrome with mild DJD [degenerative joint disease]-this is normal wear and tear and is very common for a 49 y/o male.” The examiner further noted that “Although this veteran states he was injured in a car bomb, his current diagnosis of left knee patellofemoral syndrome with mild DJD has no cause or relationship to the car bomb or service.” The Veteran again underwent a VA examination in September 2020. This examination was conducted by a physiatrist. The Veteran stated that “pain in back and left knee started after he was thrown against a desk during a car [bombing] in 1988 while attending an USO ship party in Naples, Italy.” It was again noted that the Veteran “was not treated while in service and was able to complete his service without any problems. However, his pain got worse over years.” Based on review of the record and interview and examination of the Veteran, the VA examiner diagnosed osteoarthritis that was not incurred in or caused during active service, including the April 1988 car bomb. The examiner stated that it is less likely as not that his current left knee disability is related to service. In the rationale, the examiner noted that “All available [service treatment records] and [the Veteran’s claims file] are completely silent for documented any [sic] acute injury to left knee nor any knee symptoms that might be caused by reported car bomb on 4-14-1988 during service.” The examiner further noted that the service treatment records and post-service medical records were “completely silent for any kind of knee condition at any time during service nor at any time until 12/04/2008.” The examiner noted that the December 2008 record states that the Veteran had started having a problem with his knee approximately three months earlier, and he went to an orthopedist who performed x-rays of his knee. The examiner stated that the Veteran’s knee disability is not caused by service, to include the car bombing. In the rationale, the examiner cited a “lack of any documented injury/trauma to left knee while in service and lack of the chronicity of left knee problem following service until years after his military separation.” The examiner noted that such an injury (from a car bomb explosion) “usually will cause acute or subacute (days or weeks) pain/or symptoms in knee. Therefore, the complete absence of medical records of any trauma/injury and associated symptoms in left knee while in service is medically significant.” The examiner further stated that “The pathology/disease process associated with the Veteran’s left knee (DJD) is not consistent with the mechanism of injury (car bomb injury in 1988) claimed by the Veteran.” The examiner then noted that “The pathology/disease process associated with the Veteran’s left knee (DJD) is consistent with the mechanism of aging process which is well established and supported by peer reviewed medical literatures.” The examiner noted that degenerative joint disease, also referred to as osteoarthritis, “is a common ‘wear and tear’ disease that occurs when the cartilage that serves as a cushion in the joints deteriorates. This condition can affect any joint but is most common in knees, hands, hips, and spine.” The September 2020 VA examiner included multiple citations to pertinent medical literature to support this opinion. As noted above, the requested examination was conducted by a physiatrist rather than an orthopedic surgeon. As explained above, however, the Board finds that full compliance with the Board’s remand instruction (that the examination must be conducted by an orthopedic surgeon) was not possible. The RO complied with the Board’s instruction to the fullest extent possible in attempting to schedule an examination with an orthopedist. As noted above, the Board finds that the physiatrist who did conduct the examination and provide the requested opinion was properly qualified to do so. See Cox v. Nicholson, 20 Vet. App. 563 (2007). Also as with the back opinion, the VA examiner’s left knee rationale includes an inaccurate timeline of post-service left knee complaints. Specifically, the VA examiner noted that the service treatment records and post-service medical records were “completely silent for any kind of knee condition at any time during service nor at any time until 12/04/2008.” However, the Board notes that the medical evidence of record reflect that the Veteran sought post-service knee treatment as early as June 2007. Records from that period reflect that the Veteran “slipped on the floor and dislocated his left knee” and that he had knee surgery shortly thereafter. As with the back disability claim discussed above, the Board finds that this misstatement of the Veteran’s post-service medical history does not undermine the examiner’s analysis. The examiner was aware of the approximate timeline of the Veteran’s post-service left knee medical history, and the examiner’s error does not undermine the cited rationale. Specifically, the examiner determined that “The pathology/disease process associated with the Veteran’s left knee (DJD) is consistent with the mechanism of aging process which is well established and supported by peer reviewed medical literatures.” The Board therefore finds that the probative value of the September 2020 VA examiner’s opinion is not undermined by this error. The Board also observes that the VA examiner did not note that the Veteran complained of a history of, or current, trick or locked knee at the time of his May 1991 separation medical history report. The Board notes, however, the examiner’s discussion of the Veteran’s service treatment records emphasizes the fact that no knee abnormalities were documented during service, including at the time of his May 1991 separation examination. The examiner specifically noted “All available [service treatment records] and [the Veteran’s claims file] are completely silent for documented any [sic] acute injury to left knee nor any knee symptoms that might be caused by reported car bomb on 4-14-1988 during service, and that the service treatment records and post-service medical records were “completely silent for any kind of knee condition at any time during service….” In short, the VA examiner’s opinion relies on an absence of actual findings of left knee abnormalities, which is an accurate understanding of the Veteran’s service treatment records. The Board thus finds that the examiner not mentioning of the May 1991 notation of history of knee complaint does not undermine the resulting rationale. The Board thus finds that this opinion is highly probative, as it is based on review of the record and interview and examination of the Veteran. It contains a rationale that cites to the facts of the Veteran’s case and pertinent medical principles. As discussed above, the Board finds that the rationale relies on a medical rationale that does not involve any factual misunderstandings that the examiner may have had with respect to this case. The VA examiner set forth a medical reason to reject the proposition that the Veteran’s exposure to a bomb explosion left chronic knee residuals as such an injury would have required medical attention. The Veteran’s assertion that he had knee pain in service and ever since service is not credible. The only remaining contrary opinion comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. Finally, there is also no persuasive medical evidence or persuasive credible lay evidence that the Veteran's claimed disorder manifested to a compensable degree within a year of his separation from service or had its onset in service and continued ever since service. Therefore, service connection based on presumptive service connection for a chronic disease or based on a theory of continuity of symptomatology is not warranted. Accordingly, the Board must find that entitlement to service connection for a left knee disability is not warranted on a direct basis or on a presumptive basis based on chronic disability. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. REASONS FOR REMAND 1. Entitlement to a TDIU is remanded. The Board notes that the evidence of record does not contain information that would allow the Board to properly adjudicate this claim. Specifically, the evidence of record does not provide a comprehensive description of the functional impairments that are caused by each of the Veteran’s service-connected disabilities. The Veteran should therefore be scheduled for VA examinations for his service-connected disabilities to assess the functional impairments caused by these disabilities. The matters are REMANDED for the following action: 1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include any VA medical records that were created since the Veteran’s records were last obtained. 2. Schedule the Veteran for examinations with appropriate examiners to determine the functional impairment for employability purposes for each of his service-connected disabilities. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed, and all findings should be reported in detail. Specifically, the examiner should fully describe the functional impairment that is caused by each of the Veteran’s service-connected disabilities. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Elizabeth Jalley, 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.