Citation Nr: 21008675 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 14-29 222 DATE: February 17, 2021 ORDER Entitlement to an initial rating in excess of 10 percent disabling for service-connected right ankle strain is denied. Entitlement to service connection for a left ankle disability, to include as secondary to service-connected right ankle strain, is denied. Entitlement to service connection for a right knee disability, to include as secondary to service-connected right ankle strain, is denied. Entitlement to service connection for a left knee disability, to include as secondary to service-connected right ankle strain, is denied. Entitlement to service connection for an acquired psychiatric disability to include obsessive compulsive disorder, other specified depressive disorder as well as anger dysregulation, adjustment disorder with anxiety, major depressive disorder, and posttraumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. For the entire appeal period, the Veteran’s right ankle strain is manifested by no more than moderate limited motion, even in contemplation of functional loss due to symptoms such as pain, weakness, swelling, fatigability, incoordination, or repetitive motion, or as a result of repetitive motion and/or flare-ups, and does not result in ankylosis, malunion of the os calcis or astragalus, or astragalectomy. 2. At no time during, or prior to, the pendency of the claim does the Veteran have a current diagnosis of a left ankle disability. 3. A right knee disability is not shown to be causally or etiologically related to any disease, injury, or incident in service, did not manifest within one year of service discharge, and was not caused or aggravated by the Veteran’s service-connected right ankle strain. 4. A left knee disability is not shown to be causally or etiologically related to any disease, injury, or incident in service, did not manifest within one year of service discharge, and was not caused or aggravated by the Veteran’s service-connected right ankle strain. 5. An acquired psychiatric disability, to include obsessive compulsive disorder, other specified depressive disorder as well as anger dysregulation, adjustment disorder with anxiety, major depressive disorder, and PTSD, did not manifest in service, is not shown to be causally or etiologically related to any disease, injury, or incident during service and psychosis did not manifest within one year of service discharge. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent disabling for service-connected right ankle strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. 2. The criteria for service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for a right knee disability to include as secondary to service-connected right ankle strain have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for a left knee disability to include as secondary to service-connected right ankle strain have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 5. The criteria for service connection for an acquired psychiatric disability, to include obsessive compulsive disorder, other specified depressive disorder as well as anger dysregulation, adjustment disorder with anxiety, major depressive disorder, and PTSD, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from July 1985 to July 1995. The Board must discuss all theories of entitlement raised by the Veteran or by the evidence of record. Robinson v. Mansfield, 21 Vet. App. 545 (2008). Accordingly, the Board has recharacterized the claims as indicated above to afford the Veteran the broadest possible scope of review. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). In August 2017, the Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge. A hearing transcript has been associated with the record. The Board notes that these claims were previously before the Board in March 2018. At such time, the Board remanded the claims for further development and adjudication. The Board finds there has been substantial compliance with the Board’s remand orders as they relate to the issues denied herein, and no further action is necessary. See D’Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). While the Veteran’s entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that, in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, are expected in all instances. 38 C.F.R. § 4.21. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). In the instant case, the record reflects that the Veteran’s right ankle was examined by VA in June 2012, March 2015, and October 2020. Upon a review of the VA examination reports, the Board notes that there was evidence of pain on weight-bearing noted during the June 2012 and March 2015 examinations, but no evidence of abnormal weight-bearing at the October 2020 examination. Importantly, range of motion (ROM) testing of the undamaged paired joint was possible and conducted at all three examinations. Furthermore, while the June 2012 examination does not reflect passive ROM testing, the March 2015 noted some pain on passive ROM and October 2020 examination noted that passive ROM was the same as active. However, the evidence does not suggest, and the Veteran has not argued, that his range of ankle motion would be further limited in such capacity. Moreover, as a general matter of course, active ROM testing usually results in further limitation than passive ROM testing. See Massie v. Shinseki, 25 Vet. App. 123, 131 (2011); Robinson, supra; Scott, supra. Furthermore, the October 2020 examiner opined that the Veteran’s ankle flare-ups would not further limit his ankle ROM (as indicated by the examiner noting the exact same measurements during a flare-up) and the examiners all discussed the impact of functional loss of his right ankle disability. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Furthermore, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). Entitlement to an initial rating in excess of 10 percent disabling for service-connected right ankle strain is denied. The Veteran contends that his right ankle strain is worse than is reflected by his currently assigned rating. The Veteran has been assigned an initial 10 percent rating for his right ankle strain pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5271. Under Diagnostic Code 5271, moderate limitation of motion of an ankle warrants a 10 percent rating, while marked limitation of motion of an ankle warrants a 20 percent rating. For reference purposes, the normal ranges of motion in the ankle include 20 degrees of dorsiflexion and 45 degrees of plantar flexion. See 38 C.F.R. § 4.71, Plate II. Also included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate other impairment resulting from ankle disorders, including Diagnostic Code 5270 (ankylosis), Diagnostic Code 5272 (ankylosis of the subastragalar or tarsal joint), Diagnostic Code 5273 (malunion of the os calcis or astragalus), and Diagnostic Code 5274 (astragalectomy). After reviewing the evidence of record, the Board finds that an initial rating in excess of 10 percent is not warranted for the Veteran’s right ankle strain. As an initial matter, ankylosis is expressly not shown by the evidence as noted by the June 2012, March 2015 and October 2020 VA examiners. Furthermore, there is no evidence of malunion of the os calcis or astragalus, or astragalectomy. Thus, the criteria of Diagnostic Codes 5270, 5272, 5273, and 5274 do not apply. Additionally, a higher 20 percent rating under 5271 is not warranted for the Veteran’s right ankle strain as there is no evidence of limitation of motion or functional loss that would equate to marked limitation of motion of the ankle. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. Specifically, while the Veteran has reported experiencing pain on motion and limitations in prolonged walking or standing, the RO has already assigned a 10 percent rating based on his painful motion, despite the fact that the Veteran had full range of motion of his right ankle at the October 2020 examination. Indeed, even at the June 2012 and March 2015 examinations where he did demonstrate reduced motion in his ankle to 15 degrees dorsiflexion and 35 degrees plantar flexion, he was not noted to have “moderate” loss of motion as identified in VA’s Adjudication Procedures Manual (Manual) during the examination. In this regard, the Manual states that moderate limitation of ankle motion is present when there is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, while marked limitation of motion is demonstrated when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. VBA Manual M21-1, III.iv.4.A.3.k. In any case, the initially assigned 10 percent rating contemplates up to moderate limitation of motion, which the Veteran has not demonstrated at any point during the appeal period. Finally, a higher 20 percent rating is not warranted as the ankle does not have less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion at any point during the appeal. Id. In sum, as the evidence does not demonstrate marked limitation of motion, ankylosis, malunion of the os calcis or astragalus, or astragalectomy at any point during the appeal period, the criteria for a higher initial rating for the Veteran’s right ankle strain is not warranted. The Board has carefully reviewed and considered the Veteran’s statements regarding the severity of his service-connected ankle disability. The Board also acknowledges that the Veteran, in advancing this appeal, believes that said disability has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report his observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). Nevertheless, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. Thus, the Veteran’s lay assessments as to the severity of the symptoms and their relationship to the rating criteria are deemed less probative than the opinions of medical practitioners who have specialized knowledge and skill in excess of the Veteran. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran’s service-connected right ankle strain; however, the Board finds that his symptomatology has been stable throughout the appeal. Therefore, assigning staged ratings is not warranted. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. Doucette v. Shulkin, 28 Vet. App. 366 (2017), (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § §§ 1110, 1131; 38 C.F.R. § § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § § 3.303 (d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. § §§ 1101, 1112, 1137; 38 C.F.R. § §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § § 3.309 (a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § § 3.303 (b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). The requirement of a current disability is satisfied when the Veteran has a disability at the time, he files his service connection claim or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, when the record contains a recent diagnosis of disability prior to the Veteran’s filing of a claim for benefits based on that disability, the report of the diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Under applicable regulation, the term “disability” means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 292 (1991). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). 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). Furthermore, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310 (b). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § § 5107 (b); 38 C.F.R. § § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Entitlement to service connection for a left ankle disability, to include as secondary to service-connected right ankle strain, is denied. The Veteran generally contends that he suffers from a left ankle disability that is the result of his service or in the alternative is secondary to his service-connected right ankle strain. The Veteran’s service treatment records are silent for any complaints, treatment or diagnosis of a left ankle disability. The Veteran subsequently has reported that he strained his left ankle during service while playing basketball, however there is no documentation of such an injury in his contemporaneous treatment records. Treatment records from February 1988 do reflect that the Veteran sprained his right ankle while playing basketball, but there is no reference to his left ankle. Furthermore, during a medical examination conducted in March 1992 prior to the Veteran’s discharge, the examiner noted that the Veteran had sprained his right ankle, but there was no mention of the Veteran’s left ankle. The Veteran’s post-service treatment records reflect reports of left ankle pain however they are silent for any diagnosis of a left ankle disability. Furthermore, while the Veteran has generally reported that his claimed left ankle disability began in or was caused by his active duty service, the evidence of record does not support the Veteran’s claim. There is simply no indication of any left ankle disability. However, the Veteran was provided with VA examinations in June 2012, March 2015, and October 2020. In June 2012 the Veteran underwent a VA Ankle Conditions examination with an accompanying Disability Benefits Questionnaire (DBQ). The examiner noted the Veteran’s right ankle sprain, but did not note any left ankle diagnoses. The Veteran reported bilateral ankle pain aggravated by long periods of walking. Upon examination, the Veteran’s left ankle plantar flexion was to 35 degrees with pain at 35 degrees and plantar dorsiflexion was to 15 degrees with pain at 15 degrees. The examiner provided an etiological opinion as to the Veteran’s right ankle sprain, but did not provide any opinion as to the Veteran’s left ankle complaints. In March 2015 the Veteran underwent another VA Ankle Conditions examination with an accompanying DBQ. The examiner noted that the Veteran suffered from lateral collateral ligament sprain on the right. However, the examiner noted no left ankle diagnosis. The Veteran reported the onset of left ankle pain approximately two years prior to the examination, but stated that he could not recall any specific injury other a twisting injury in service while playing basketball. He noted intermittent pain and swelling as well an unstable sensation. The Veteran also noted flare-ups of pain and noted that he avoided sporting activities. Upon examination, the Veteran’s dorsiflexion was to 10 degrees and his plantar flexion was to 30 degrees. The examiner stated that the Veteran had limited range of motion in both ankles, left greater than right. However, the examiner noted that the Veteran’s gait was not significantly affected. The examiner noted that the Veteran attributed his left ankle pain to his service-connected right ankle disability, however the examiner noted that the medical literature does not support development of a contralateral ankle condition secondary to an existing ankle condition. Rather the examiner found that the Veteran’s claimed left ankle pain was the result of his post-service job as a letter carrier. Therefore, the examiner found that it was less likely than not that the Veteran’s claimed left ankle condition was incurred in or caused by the service-connected right ankle condition. In October 2020 the Veteran underwent an additional VA Ankle Conditions examination with an accompanying DBQ. The examiner again noted the Veteran’s right ankle condition/right ankle sprain. However, the examiner provided no diagnosis for a left ankle disability. Upon examination, the examiner found that the Veteran’s ankles both exhibited normal range of motion without any evidence of pain upon examination. The examiner opined that the Veteran’s claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner provided the rationale that there was no objective evidence and thus no diagnosis of a left ankle disability. Therefore, the claimed left ankle condition is less likely than not caused by the claimed ankle sprain while playing basketball. The examiner again noted that no current diagnosis was rendered. The examiner also opined that the Veteran’s claimed condition is less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner provided the rationale that the Veteran’s claimed left ankle sprain and his right ankle sprain are unrelated as again the Veteran has no current left ankle diagnosis, as again there was on objective evidence of such. The Board finds that service connection is not warranted for the Veteran’s claimed left ankle disability as the probative evidence of record fails to demonstrate a current disability related to the Veteran’s military service or secondary to his service-connected right ankle disability. In the instant case, the probative evidence of record fails to demonstrate a current diagnosis of a left ankle disability. While the Board has also considered the Court’s holding in Romanowsky, supra, there is also no probative evidence of a recent diagnosis of a left ankle disability prior to the Veteran’s claim. The Veteran’s service treatment records and post-service treatment records are silent for any complaints, treatment or diagnoses of any chronic left ankle disability. In this regard, the Board notes that the Veteran is competent to report his own symptoms or matters within his personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In addition, laypersons may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (the Board’s categorical statement that ‘a valid medical opinion’ was required to establish nexus, and that a layperson was ‘not competent’ to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, the matter of a medical diagnosis for a disability not capable of lay observation, such as that of issue here, is a matter within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Specifically, to diagnosis of a chronic left ankle disability involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of specialized testing. In the instant case, there is no suggestion that the Veteran has had any medical training. Therefore, as the Veteran does not have the appropriate medical training and expertise to competently self-diagnose a chronic left ankle disability, the lay assertions in this regard have no probative value. Jandreau, supra at 1377 n.4 (“[s]ometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. §§ 1110; 38 C.F.R. §§ 3.30, 3.310. Thus, where, as here, the probative evidence indicates that the Veteran does not have a current diagnosis of a chronic left ankle disability for the entire appeal period, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer, supra. Even if the Board were to presume that the Veteran did have a left ankle disability, service connection would still not be warranted. In regard to presumptive service connection, the Board notes that the clinical evidence of record fails to show that the Veteran manifested left ankle symptoms within the one year following his discharge from service in July 1995. There is simply no medical evidence suggesting that this occurred. Rather the earliest record of any complaints of left ankle pain were in 2012, approximately 15 years after the Veteran’s discharge. As such, even in the light most favorable to the Veteran, presumptive service connection and service connection based on continuity of symptomatology are not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In regard to direct service connection, the Board again notes that the Veteran’s claimed left ankle disability was not diagnosed during his military service, and complaints of left ankle pain were not noted for many years thereafter. As was noted above, the Veteran’s service treatment records are silent for any complaints, diagnosis or treatment for a left ankle disability or any incident or injury related to such. However, despite the lack of in-service complaints or injury, diagnosis or evidence of a current disability, the March 2015 and October 2020 VA examiners provided negative etiological opinions, finding that the Veteran’s claimed left ankle disability was not incurred in or caused by his active duty service. As the March 2015 and October 2020 examiners provided sound medical explanations and rationales for their opinions, the Board finds them very probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Furthermore, there are no contrary opinions of record. As such, even in the light most favorable to the Veteran, direct service connection is not warranted. Furthermore, as for secondary service connection, the October 2020 examiner found that the Veteran’s claimed left ankle disability was less likely than not caused by his service-connected right ankle sprain. While the examiner did not provide an opinion as to the aggravation prong of secondary service connection, the examiner’s rationale was that the Veteran does not have a left ankle disability therefore it could not be the result of his right ankle sprain. Such rationale negates the need for any further analysis by the examiner. As the October 2020 examiner provided sound medical explanations and rationales for his opinion, the Board finds it very probative. See Nieves-Rodriguez, 22 Vet. App. at 295; Stefl, 21 Vet. App. at 124. Furthermore, there are no contrary opinions of record. As such, again even in the light most favorable to the Veteran, secondary service connection is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a left ankle disability to include as secondary to service-connected right ankle strain. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Entitlement to service connection for right and left knee disabilities, to include as secondary to service-connected right ankle strain, are denied. The Veteran contends that service connection is warranted for his right and left knee disabilities as a result of his active duty service or in the alternative as secondary to his service-connected right ankle strain. The Veteran’s service treatment records are silent for any complaints, treatment or diagnosis of left or right knee disabilities. The Veteran reported that he suffered knee injuries while playing sports in the service, however the contemporaneous medical records are silent for such injuries. Furthermore, upon examination in March 1992, prior to the Veteran’s discharge, there was no mention of his knees or any related injuries or pain. However, post-service treatment records reflect the Veteran’s complaints of pain, swelling, and instability beginning in 2013. Furthermore, the Veteran was diagnosed with bilateral knee strain post-service to include at his VA examinations in March 2015 and August 2020. In March 2015 the Veteran underwent a VA Knee and Lower Leg Conditions examination with an accompanying DBQ. The examiner noted the Veteran’s bilateral knee strain. The Veteran reported that he began to suffer knee pain in service, and that he injured his left knee while playing basketball. However, he did not report any injuries to his right knee. He noted pain in both knees with intermittent swelling, heat and instability. Upon examination, his range of motion was 0 to 55 degrees flexion and 55 to 0 degrees extension. The examiner found that the Veteran had limited range of motion in both knees secondary to pain. Furthermore, the examiner noted that the medical literature did not support the Veteran’s contention that he developed bilateral knee conditions as a consequence of an ankle condition. The examiner noted that the Veteran’s gait was slow but not significantly abnormal and therefore unlikely to have contributed to the Veteran’s knee pain. The examiner found no evidence of arthritis or any inflammatory condition. Therefore, the examiner found that it was less likely than not that the Veteran’s current knee conditions are proximately due to or the result of the Veteran’s service-connected right ankle sprain. In August 2020 the Veteran underwent an additional VA Knee and Lower Leg Conditions examination with an accompanying DBQ. The examiner noted that the Veteran suffered from bilateral knee strain. The Veteran reported that he injured his knees during service playing sports but that his service-connected right ankle aggravated his conditions. He reported pain, difficulty standing and walking and that standing caused flare-ups. Upon examination, the Veteran’s flexion was 0 to 100 degrees and his extension was 100 to 0 degrees for both knees. The examiner opined that the Veteran’s claimed conditions were less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner provided the rationale that the medical records do not support that any currently diagnosed knee conditions are at least as likely as not incurred in or caused by any knee strain in service or that any knee condition was caused by or is otherwise related to the Veteran’s active duty service. The examiner also found that the claimed conditions were less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner provided the rationale that there was no medical evidence that supported the contention that the Veteran’s bilateral knee conditions were at least as likely as not proximately due to or the result of the Veteran’s service-connected right ankle sprain. Finally, the examiner opined that the Veteran’s bilateral knee conditions were less likely than not aggravated beyond their natural progression by the Veteran’s right ankle sprain. The examiner stated that there was no medical evidence to support the contention of aggravation. Throughout the appeal the Veteran has submitted statements in which he alleges that his bilateral knee disabilities are the result of his service or in the alternative secondary to his service-connected right ankle sprain. During the Veteran’s August 2017 hearing, he stated his belief again. He testified that he began experiencing bilateral knee pain in service. However, he also noted his belief that his current bilateral knee disabilities were the result of his service-connected right ankle sprain. After a thorough review of the record, the Board finds that service connection for bilateral knee disabilities is not warranted on any basis to include presumptive, direct or secondary service connection. As an initial matter, the Board finds the evidence clearly shows the Veteran has symptoms related to bilateral knee disabilities, but as previously noted there was no report of any complaints, treatment or diagnoses related to such in service. However, the first element of service connection either presumptive, direct or secondary has been met. In regard to presumptive service connection, the Board notes that the clinical evidence of record fails to show that the Veteran manifested right or left knee disabilities within the one year following his discharge from service in July 1995. There is simply no medical evidence suggesting that this occurred. Rather the earliest record of any complaints of knee pain were in 2011, approximately 16 years after the Veteran’s discharge. As such, presumptive service connection is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In regard to direct service connection, the Board again notes that the Veteran’s bilateral knee disabilities were not diagnosed during his military service, or as noted previously, for many years thereafter. As was noted above, the Veteran’s service treatment records are silent for any complaints, diagnosis or treatment for right or left knee disabilities or any incident or injury related to such. As there is no credible evidence that the Veteran was diagnosed with or exhibited symptoms of right or left knee disabilities during his military service, no examination or opinion is necessary to decide such aspect of his claims. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (holding that VA is not required to provide a medical examination when there is not credible evidence of an event, injury or disease in service). However, the October 2020 examiner did provide an etiological opinion which addressed direct service connection, as the Veteran claimed his bilateral knee pain began in service. The October 2020 VA examiner opined that the Veteran’s bilateral knee disabilities were less likely than not incurred in or caused by the claimed in-service injury, event or illness or are otherwise related to the Veteran’s active duty service. The examiner provided the rationale that the medical records do not support such a contention, noting no evidence of complaints or injury to the knees in service or for many years following the Veteran’s discharge. As the August 2020 examiner provided sound medical explanations and rationales for his opinion, the Board finds it very probative. See Nieves-Rodriguez, 22 Vet. App. at 295; Stefl, 21 Vet. App. at 124. Additionally, there are no contrary opinions of record. Furthermore, the contemporary medical evidence does not support a finding that the Veteran’s conditions began in service or supports chronicity of such symptoms. The Veteran’s post-service medical record is negative for any complaints, treatment, or diagnosis of right or left knee problems until 2013. The Board acknowledges the Veteran’s allegation that his disabilities began in or are the result of his service. However, he is not competent to diagnose or speak to the etiology of complex medication conditions. As fundamental elements of direct service connection, the in-service and nexus elements, are missing, the Board finds that direct service connection is not warranted for the Veteran’s claims for bilateral knee disabilities. As for secondary service connection, both the March 2015 and August 2020 examiners found that the Veteran’s bilateral knee disabilities were less likely than not caused by his service-connected right ankle sprain. Furthermore, while the March 2015 examiner failed to discuss the aggravation prong of secondary service connection, the August 2020 examiner specifically found that the Veteran’s bilateral knee disabilities were less likely than not permanently aggravated by his service-connected right ankle sprain. As the August 2020 examiner provided sound medical explanations and rationales for his opinion, the Board finds it very probative. See Nieves-Rodriguez, 22 Vet. App. at 295; Stefl, 21 Vet. App. at 124. Furthermore, there are no contrary opinions of record. As such, secondary service connection is not warranted. The Board has also considered the Veteran’s statements that his bilateral knee disabilities are related to his service or his service-connected right ankle sprain. In this regard, a layperson is competent to report on that of which he or she has personal knowledge. See Layno, 6 Vet. App. at 469. A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as a fall leading to a broken leg. Jandreau, 492 F.3d at 1376-77. However, the question of causation or aggravation of bilateral knee disabilities involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. In this regard, such an opinion requires specialized knowledge of several internal bodily systems. There is no indication that the Veteran possesses such specialized knowledge. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s opinion regarding the etiology of his bilateral knee disabilities is non-probative evidence. See Jandreau, supra; Woehlaert, 21 Vet. App. at 456. Moreover, the Veteran has offered only conclusory statements regarding the relationship between his bilateral knee disabilities and his service and service-connected right ankle sprain. In contrast, the VA examiners took into consideration all the relevant facts in providing opinions. Therefore, the Board accords great probative weight to the VA examiners’ opinions. Consequently, the Board finds that the Veteran’s bilateral knee disabilities are not shown to be causally or etiologically related to a disease or injury incurred in or aggravated during active service, and are not caused or aggravated by any of the Veteran’s service-connected disabilities, to include his right ankle sprain. Therefore, service connection for such claimed disability is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claims of entitlement to service connection for bilateral knee disabilities. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Entitlement to service connection for an acquired psychiatric disability to include obsessive compulsive disorder, other specified depressive disorder as well as anger dysregulation, adjustment disorder with anxiety, major depressive disorder, and PTSD is denied. The Veteran contends that service connection is warranted for his acquired psychiatric disability to include obsessive compulsive disorder, other specified depressive disorder as well as anger dysregulation, adjustment disorder with anxiety, major depressive disorder, and PTSD as a result of his active duty service. The Veteran’s service treatment records reflect treatment for spousal abuse, to include anger management. However, there are no further notations, complaints, treatment or diagnosis of an acquired psychiatric disability. During the separation examination, there were no reports of or notations of any mental health conditions. The Veteran subsequently reported that he had been the victim of an armed robbery and witnessed the assault of a young girl while stationed abroad in the middle east, however there are no contemporaneous notations or reports of such. Post-service treatment records are silent for any complaints, treatment or diagnosis of a psychiatric condition until 2012 when the Veteran went for his first VA Mental Health Conditions examination. While the examiner did not diagnose any mental health conditions, the Veteran reported sleep trouble and anger management issues. However subsequent to the 2012 examination, the Veteran was diagnosed with various mental health conditions to include obsessive compulsive disorder, other specified depressive disorder as well as anger dysregulation, adjustment disorder with anxiety, major depressive disorder, and PTSD. In June 2012 the Veteran underwent a VA Mental Health examination with an accompanying DBQ. The examiner determined that the Veteran had never been diagnosed with an acquired psychiatric disability. The examiner noted that any anger management issues that the Veteran may have had were not related to any anger management issues that he had during service. Furthermore, the examiner noted that the Veteran denied any current symptoms. In addition, the examiner found that while the Veteran may have had clinically significant PTSD at the time of his military service (possibly as a result of the alleged witnessing of an assault of a young girl), he did not report any current signs or symptoms of a mental disability. Therefore, as the examiner found that the Veteran did not have or ever have an acquired psychiatric disability, he did not provide a nexus opinion. In April 2016 the Veteran underwent an additional VA Mental Health examination with an accompanying DBQ. The examiner found that the Veteran met the diagnostic requirements for obsessive compulsive disorder as well as other specified depressive disorder. The Veteran reported depression, mood swings, lack of motivation, poor sleep, low energy, poor concentration and less interest in once preferred activities. The examiner found that the Veteran’s symptoms and reported stressors did not meet the diagnostic criteria for PTSD. Furthermore, the examiner opined that the Veteran’s acquired psychiatric disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner provided the rationale that the Veteran’s primary diagnosis is obsessive compulsive personality disorder and depression, but that his service treatment records are silent for symptoms related to such. Furthermore, the VA examination in 2012 also failed to show any such related symptoms or diagnoses. Therefore, the examiner found that the Veteran’s current acquired psychiatric disabilities were less likely as not related to, incurred in or caused by his noted anger problems in service or as a result of fear of hostile military and/or terrorist activity from his time in service. In May 2016 the Veteran underwent a VA PTSD examination with an accompanying DBQ. The examiner found that the Veteran was not currently nor had he ever been diagnosed with PTSD. Furthermore, the examiner found that the Veteran’s current acquired psychiatric disabilities, other specified depressive disorder, appeared to be related to post military life stressors. In August 2017 the Veteran submitted a statement from a private therapist, L.A.M., an LPC. She found that the Veteran suffered from PTSD and major depressive disorder. While L.A.M. opined in the August 2017 letter that his diagnoses of PTSD and major depressive disorder were caused by his experiences in service, L.A.M. failed to provide any supporting rationale or reconcile the April 2016 VA examiner’s findings with her own. Cf. Nieves-Rodriguez, 22 Vet. App. at 303-04; cf. also See Stefl, 21 Vet. App. at 123, citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994). As a result, the August 2017 Letter from L.A.M. is inadequate to adjudicate this claim. In September 2019 the Veteran submitted an additional letter from L.A.M. Unfortunately, it is essentially the same as the August 2017 letter. Again L.A.M. failed to provide any supporting rationale or reconcile the April 2016 VA examiner’s findings with her own. Therefore, while L.A.M. again found that the Veteran suffered from PTSD and major depressive disorder and that such were caused by his experiences in the service, as a result of the above deficiencies the opinion is inadequate to adjudicate this claim. In August 2020 the Veteran underwent an additional VA Mental Health Conditions examination with an accompanying DBQ. The examiner found that the Veteran suffered from other specified depressive disorder, with anxious distress. The examiner noted that the Veteran did not have any additional acquired psychiatric disabilities. After a thorough review of the record, the examiner found that the Veteran’s other specified depressive disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner provided the rationale that there was a lack of temporal association between the stated stressor in 1991 and the onset of psychiatric symptoms. The examiner noted that “anger management” and domestic violence are neither recognized psychiatric diagnoses, nor sufficient evidence of the presence of a psychiatric diagnosis. Furthermore, the examiner noted that the Veteran reported witnessing the assault of a young girl while serving abroad, but found that such a stressor did not meet the criteria for PTSD. Therefore, the examiner found a diagnosis of PTSD to be impossible. The examiner noted that upon the Veteran’s return from service he was able to sustain relational abilities and married in 1992. Furthermore, while there was evidence of domestic violence in 1993 and 2006, there was no evidence of psychiatric symptoms post service. The examiner noted that the Veteran denied psychiatric symptoms in 2012, 2013, and 2014. However, in 2016 the Veteran reported the onset of psychiatric symptoms. The Veteran was then diagnosed with adjustment disorder secondary to recent stressors, unspecified trauma and stressor related disorder. The examiner noted that adjustment disorders require onset within 3 months of exposure to a stressor. Therefore, such would require a social stressor rather than a military one. As far as the unspecified trauma and stressor related disorder, the examiner noted no attempt to reconcile such with the previous denials of symptoms on self-report. The examiner noted that in regard to “anger dysregulation,” there is no such diagnosis in the professional literature. The examiner noted that domestic violence is not caused by mental illness. Furthermore, the examiner noted that in reviewing L.A.M.’s letter there were “significant deviations” from the professional diagnostic standards. Ultimately, the examiner found it impossible to determine how L.A.M. came to her conclusions noting that she ignored the primary requirement for diagnosis and failed to mention the use of the formal method of determining causation. The Board notes that the Veteran has a current diagnosis of an acquired psychiatric disability, specifically other specified depressive disorder. While the Veteran was diagnosed with various other acquired psychiatric disabilities over the years, to include obsessive compulsive disorder, as anger dysregulation, adjustment disorder with anxiety, major depressive disorder, and PTSD, the August 2020 VA examiner thoroughly explained that the Veteran’s only valid diagnosis is other specified depressive disorder. Therefore, the first element of service connection is satisfied. The Board must then consider the different theories of entitlement to service connection. First, the Board has considered whether service connection is warranted on a presumptive basis. For the purposes of 38 C.F.R. § 3.309 (a), the term “psychosis” includes diagnoses of brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified, schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. 38 C.F.R. § 3.384. In this case, the Veteran has not been diagnosed with a psychiatric disorder deemed a psychosis for presumptive service connection purposes. In any event, the Board finds no credible lay or medical evidence that the Veteran demonstrated psychotic behavior in service or within one year from service discharge. As such, presumptive service connection is not warranted for psychosis as a chronic disease under 38 C.F.R. § 3.309 (a). The Board further observes that the Veteran, while reporting symptomology in service and thereafter, the clinical evidence of record does not document post-service complaints or treatments of a psychiatric disability until 2012, approximately 17 years after service discharge. This lengthy period without evidence of treatment tends to weigh against a finding of in-service onset. See generally Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Next the Board has considered direct service connection. Although the Veteran reported anger management issues in service, there was no indication of any treatment or diagnosis of any acquired psychiatric disabilities during his service. In addition, the August 2020 VA examiner specifically found that the Veteran’s current acquired psychiatric disability was not incurred in or caused by service. Furthermore, as previously noted the August 2020 examiner thoroughly discussed why each of the Veteran’s prior diagnoses was invalid and why the Veteran’s private therapist’s diagnosis and conclusions were erroneous. As the August 2020 examiner provided sound medical explanations and rationales for his opinions, the Board finds it very probative. See Nieves-Rodriguez, 22 Vet. App. at 295; Stefl, 21 Vet. App. at 124. The Board notes that there are no adequate contrary medical opinions of record. The Board notes that the Veteran has contended that his current acquired psychiatric disability began in or is directly related to his service. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno, 6 Vet. App. at 469-70. Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, “VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to” and a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran’s acquired psychiatric disability and any instance of his service to be complex in nature. See Woehlaert, 21 Vet. App. at 456. Here, while the Veteran is competent to describe the current manifestations of his acquired psychiatric disability and to describe his in-service symptoms, the Board accords such statements regarding the etiology of such disability little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones, 7 Vet. App. at 137. In this regard, the diagnosis of an acquired psychiatric disability requires the administration and interpretation of specialized psychiatric testing and evaluation. There is no indication that the Veteran possesses the requisite medical knowledge to perform such testing or interpret their results. Furthermore, the Veteran has offered only conclusory statements regarding the relationship between his purported in-service psychiatric symptoms or his service-connected condition and his current acquired psychiatric disability. Therefore, the Board finds that an acquired psychiatric disability first manifested many years after service and is not shown to be causally or etiologically related to any disease, injury, or incident during service. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for an acquired psychiatric disability. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Unger, 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.