Citation Nr: 21009363 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 13-33 576 DATE: February 22, 2021 ORDER Entitlement to an initial 30 percent evaluation, but no higher, for ischemic heart disease (IHD) prior to September 23, 2008, on a substitution basis is granted. Entitlement to an evaluation in excess of 30 percent for IHD on or after September 23, 2008, on a substitution basis is denied. Entitlement to an initial 30 percent evaluation, but no higher, for posttraumatic stress disorder (PTSD) prior to January 1, 2010 (excluding temporary total evaluations from July 28, 2008, to September 1, 2008, and from November 16, 2009, to January 1, 2010) on a substation basis is granted. Entitlement to an initial evaluation in excess of 70 percent for PTSD on or after January 1, 2010, on a substitution basis is denied. Entitlement to service connection for vascular disease, to include as secondary to service-connected IHD, on a substitution basis is denied. Entitlement to service connection for arthritis of the hips, legs, and back on a substitution basis is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to January 1, 2010, on a substitution basis is remanded. FINDINGS OF FACT 1. For the period prior to September 23, 2008, the Veteran’s service-connected IHD was productive of cardiac hypertrophy or dilation later confirmed on electrocardiogram, echocardiogram, or X-ray. 2. For the entire period on appeal, the Veteran’s service-connected IHD was not productive of more than one episode of acute congestive heart failure in the past year; workload of greater than 3 METs but not greater than 5 METs resulting in symptoms of dyspnea, fatigue, angina, dizziness or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 3. For the entire period on appeal, the Veteran’s PTSD was productive of occupational and social impairment in most areas, but not total occupational and social impairment. 4. The Veteran was not shown to have vascular disease that manifested in service or that it otherwise causally or etiologically related to military service or to a service-connected disability. 5. The Veteran did not have a current bilateral knee disorder that manifested in service or within one year of separation or that is otherwise related to his military service. 6. The Veteran’s degenerative disc disease of the lumbar spine and degenerative joint disease of the hips did not manifest in service or within one year of separation and were not otherwise related to his military service. CONCLUSIONS OF LAW 1. The criteria for an initial 30 percent evaluation, but no higher, for IHD prior to September 23, 2008, have been met or approximated. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1, 4.14, 4.104, Diagnostic Code 7005. 2. Throughout the appeal period, the criteria for an evaluation in excess of 30 percent for IHD have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.104, Diagnostic Code 7005. 3. The criteria for an initial 70 percent evaluation, but not higher, for PTSD prior to January 1, 2010, have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411. 4. The criteria for an initial evaluation in excess of 70 percent for PTSD on or after January 1, 2010, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411. 5. Vascular disease was not incurred in active service and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 6. Arthritis of the back, hips, and knees was not incurred in active service, nor may it be presumed to have been so incurred. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1968 to December 1969. He died in October 2016, and the appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from March 2008 and June 2011 rating decisions. In the March 2008 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for PTSD and assigned a 30 percent evaluation, effective from February 7, 2007. The AOJ also denied service connection for vascular disease; arthritis of the back, hips, and legs; heart disease; and joint disease. In the June 2011 rating decision, the AOJ granted service connection for ischemic heart disease and assigned a 10 percent evaluation, effective from April 16, 2001, and a 30 percent evaluation, effective from September 23, 2008. The AOJ also denied TDIU. In a September 2008 rating decision, the AOJ assigned a temporary total evaluation for PTSD, effective from July 28, 2008, and a 30 percent evaluation, effective from September 1, 2008. In a February 2009 rating decision, the AOJ increased the evaluation for PTSD from 30 to 50 percent, effective from February 7, 2007. Because the increased evaluation did not constitute a full grant of the benefits sought, the increased rating issue remained in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In a February 2010 rating decision, the AOJ assigned a temporary total evaluation for PTSD, effective from November 16, 2009; and a 50 percent evaluation, effective from January 1, 2010. In October 2015, the Board remanded the claims for increased evaluations for PTSD, service connection for vascular disease and arthritis, and TDIU. The case has since been returned to the Board for appellate review. In a January 2016 rating decision, the AOJ increased the evaluation for PTSD from 50 to 70 percent, effective from January 1, 2010. Because the increased evaluation did not constitute a full grant of the benefits sought, the increased rating issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In addition, in the January 2016 rating decision, the AOJ granted TDIU, effective from January 1, 2010. However, the claim for TDIU remains pending for the time period prior to January 1, 2010. See Harper v. Wilkie, 30 Vet. App. 356 (2018). In February 2020, the AOJ recognized the appellant as a valid substitute claimant. Accordingly, the appellant has been substituted as the claimant for purposes of all claims that were pending on the date of the Veteran’s death. This issues on appeal has been recharacterized on the title page to reflect such substitution. In his November 2013 substantive appeal, the Veteran requested a hearing before the Board at the AOJ. In January 2017, the appellant was informed that a hearing before the Board was scheduled in February 2017. However, in October 2020, the appellant withdrew the hearing request. Law and Analysis The appellant has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Evaluation 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 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. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where VA’s adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or “staged” ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson, 12 Vet. App. at 126-27. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Ischemic Heart Disease In this case, the Veteran’s service-connected ischemic heart disease was assigned an initial 10 percent evaluation prior to September 23, 2008, and a 30 percent evaluation thereafter, pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7005. Under Diagnostic Code 7005, a 30 percent evaluation is warranted where there is workload of greater than 5 METs but not greater than 7 METs resulting in resulting in dyspnea, fatigue, angina, dizziness or syncope; or, where there is evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram or X-ray. A 60 percent evaluation is warranted where there is evidence of more than one episode of acute congestive heart failure in the past year; or, workload of greater than 3 METs but not greater than 5 METs resulting in symptoms of dyspnea, fatigue, angina, dizziness or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent evaluation is warranted where there is chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness or syncope; or, left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET (metabolic equivalent) is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran’s disability picture was more consistent with a 30 percent evaluation throughout the entire period on appeal. For the period prior to September 23, 2008, there was evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A June 2010 VA heart examiner specifically noted that the Veteran did not have coronary artery disease or IHD at the time of the examination. The VA examiner also reported that there was no documented evidence of coronary artery disease or IHD on VA treatment problem lists. However, in an April 2011 VA IHD examination report, the VA examiner indicated that the Veteran was diagnosed with IHD in 2001 and that IHD includes, but is not limited to, acute, subacute, an old myocardial infarction; atherosclerotic cardiovascular disease, including coronary artery disease and coronary bypass surgery; and stable, unstable, and Prinzmetal’s angina. The April 2011 VA examiner also noted a history of infarction in 2001 and indicated that that there was evidence of cardiac hypertrophy or dilatation. In addition, a January 2001 VA stress test report showed mild ischemia with a left ventricle ejection fraction (LVEF) of 64 percent. Thus, given that the Veteran had an infarction in 2001, it is unlikely that the cardiac hypertrophy or dilatation suddenly appeared upon testing in 2011. Rather, it seems that the manifestations may have went undetected without testing. Therefore, resolving any favorable doubt in favor of the appellant, the Board finds that the Veteran’s IHD more closely approximated the criteria for a 30 percent evaluation for the entire period on appeal. Nevertheless, throughout the entire period on appeal, the evidence does not show that the Veteran met the criteria for an evaluation in excess of 30 percent. In order to warrant the next higher 60 percent evaluation, there must be evidence of more than one episode of acute congestive heart failure in the past year; or, workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The evidence of record does not demonstrate that the Veteran experienced more than one episode of acute congestive heart failure; that his workload was greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness or syncope; or that he had left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Indeed, a September 2008 VA stress test showed a METs level of 7, and a November 2008 VA stress test report showed a LVEF of 67 percent. An April 2011 VA echocardiogram also showed an LVEF of 59 percent. In an October 2011 VA IHD examination report, the VA examiner noted that the lowest level of activity that the Veteran reported symptoms was over 5 to 7 METs. Therefore, the Board finds that the evidence does not support the next higher schedular rating of 60 percent. PTSD The Veteran’s PTSD was assigned a 50 percent evaluation prior to January 1, 2010 (excluding temporary total evaluations from July 28, 2008, to September 1, 2008, and from November 16, 2009, to January 1, 2010), and a 70 percent evaluation thereafter, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under Diagnostic Code 9411, a 50 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when the psychiatric disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The use of the term “such as” in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant’s social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated that “a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” It was further noted that “§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran was entitled to a higher initial rating for PTSD. The Board finds that the disability picture, to include the severity, frequency, and duration of his symptoms, as well as the resulting impairment of social and occupational functioning, was more consistent with a 70 percent rating throughout the period on appeal. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Throughout the appeal, the Veteran reported that he had social impairment. Specifically, during a February 2008 VA examination, he indicated that he was married for 40 years. He explained that they divorced 12 years ago, but then they were remarried. He stated that he had four children and four grandchildren. He also reported that he had one sister and two brothers. The Veteran’s wife noted that he became irritable and grouchy easily at home. The Veteran also related that he had anger problems, especially at home. He stated that he did not socialize and that he did not like crowds. He indicated that he spent his time sitting home and watching television. He also reported that he no longer hunted or fished and that he did not go to church. In an October 2008 VA treatment note, the Veteran related that he lived with his wife of 42 years. He also stated that he enjoyed riding his four-wheeler, getting into the woods, and fly fishing. During a May 2010 VA examination, the Veteran stated that he was married for 44 years and that he had four adult children. He also reported that he had two brothers and one sister, and he related that he got along well with his family. He indicated that he spent his time at home and that he did not do much because of his anxiety outside of his home. He did note that he went to the Vet Center once a week. He related that he tried hunting, but he stopped when he felt as if he was being shot at. In February 2011 and September 2011 VA treatment notes, the Veteran reported that his wife died in December 2010 and that he was coping, but that he was depressed and somewhat anxious. In a September 2012 VA treatment note, the Veteran stated that his wife’s teenage daughter aggravated him and that he became angry with her, but he did not become physically violent. During a January 2016 VA examination, the Veteran related that he had been married twice. He stated that he was married to his first wife for 44 years before she died of heart failure. He indicated that they had four children. He reported that he remarried in the last four years. He also noted that he had one living brother and sister. He related that he stayed home and watched television, but that he went to his nephew’s ballgames sometimes. He stated that he stopped hunting and fishing in the last 15 years. Regarding occupational impairment, the evidence shows that the Veteran was a truck driver until he retired in 2001 following cardiac surgery. During a May 2007 VA mental health consultation, the Veteran reported that he started on disability due to heart problems in the past six years and that he was no longer able to work. During the February 2008 VA examination, the Veteran reported that he had a seventh-grade education and that he completed truck driver school. He indicated that he worked as a dog catcher, a street cleaner, a coal miner, at a shipyard, and as a truck driver. He related that he worked as a truck driver for over 20 years because he did not have to deal with people. During the May 2010 VA examination, the Veteran indicated that he was a retired truck driver, but that he had also worked in coal mines and for the city. He stated that his longest employment was truck driving and that it was his best job because he did not have to deal with people. He stated that he had not worked in the past eight years due to chronic back pain issues and other medical issues. During the July 2012 hearing, the Veteran stated that he had terrible PTSD symptoms when he worked alone. He stated that, if someone cut him off while he was driving a truck, he wanted to run them over. During the January 2016 VA examination, the Veteran reported that he had an eighth-grade education and that he did not get a GED. He stated that, following service, he worked in coal mines for seven years. He also worked in a shipyard, worked for the city, and drove a truck. He related that he had not worked since 2000. As to symptoms, throughout the appeal, the Veteran endorsed anxiety, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, and visual hallucinations. See, e.g., February 2008, May 2010, January 2016 VA examination reports, July 2012 hearing transcript. In the May 2010 VA examination report, the VA examiner noted that the Veteran’s symptoms had increased in severity following an earthquake in Haiti and his son’s deployment to Iraq. The examiner indicated that the Veteran continued to be hypervigilant around crowds; he became anxious and nervous around crowds; he avoided crowds; and he had associated mood problems, irritability, and avoidance behavior. The examiner opined that the Veteran’s symptoms were moderate to severe in severity. Moreover, the May 2010 VA examiner noted that the Veteran’s symptoms did affect him socially and economically. Specifically, the examiner related that the Veteran limited himself mostly to home and that he had difficulty socializing. The January 2016 VA examiner opined that the Veteran’s PTSD manifested in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, which is commensurate with a 70 percent evaluation. Based on the foregoing, the Board finds that the Veteran had occupational and social impairment with deficiencies in most areas throughout the appeal period. Therefore, a 70 percent evaluation is warranted for PTSD for the entire period remaining on appeal. Nevertheless, the record does not demonstrate that the Veteran’s overall disability picture was consistent with a 100 percent rating or higher during the appeal period. To the extent these symptoms may be shown or argued, the Board finds that the Veteran’s PTSD has not been shown to be productive of total occupational and social impairment to warrant a 100 percent rating. A 100 percent rating is warranted when the psychiatric disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The Board emphasizes that a 100 percent disability evaluation requires both total social and occupational impairment. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive “and” in a statutory provision meant that all of the conditions listed in the provision must be met); cf. Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive “or” requirement must be met in order for an increased rating to be assigned). In this regard, the Board acknowledges the Veteran’s lay statements regarding the severity of his symptoms. However, throughout the appeal period, the Veteran was not been shown to have had both total occupational or social impairment. As to social impairment, the evidence suggests that the Veteran maintained a relationship with his wives, children, grandchildren, brothers and sister, and nephew throughout the appeal period. Thus, although he had significant social impairment, the evidence shows that the Veteran has maintained relationships throughout the appeal period. As such, it cannot be said that the Veteran has had total social impairment. Concerning occupational impairment, the evidence suggests that the Veteran may have had some significant occupational impairment; however, the evidence also shows that he was retired throughout the appeal period. During the May 2010 VA examination, the Veteran stated that he had not worked in the past eight years due to chronic back pain issues and other medical issues. Thus, it cannot be said that the Veteran had total occupational impairment due to his PTSD during the appeal period. The Veteran’s PTSD symptoms, when taken together, did not more nearly approximate both total social and total occupational impairment as required to warrant a 100 percent rating. Mauerhan, supra, Vazquez-Claudio, supra. The criteria for the next higher rating of 100 percent have not been met or approximated. See 38 C.F.R. § 4.130, Diagnostic Code 9411. After considering the evidence of record, the Board finds that the Veteran’s PTSD more closely approximates the criteria for the 70 percent disability rating for the entire appeal period. Overall, the Veteran had not demonstrated a level of impairment consistent with the criteria for a total evaluation. Mauerhan, supra, Vazquez-Claudio, supra. The criteria for a total evaluation have not been met or approximated at any time during the appeal period. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Thus, the Board concludes that the weight of the evidence is against a rating in excess of 70 percent for PTSD for the entire appeal period. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As arthritis is a chronic disease for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. However, peripheral vascular disease is not an enumerated “chronic disease” listed under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions based on “chronic” symptoms in service, and “continuous” symptoms since service at 38 C.F.R. § 3.303(b) do not apply here. Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). A disability may also be service-connected on a secondary basis if it is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a). Moreover, secondary service connection may be established by any increase in severity (i.e., aggravation) of a nonservice-connected condition that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(b); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995); Tobin v. Derwinski, 2 Vet. App. 34, 39 (1991). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Vascular Disease In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for peripheral vascular disease or peripheral artery disease. The Veteran’s service treatment records are negative for any complaints, treatment, or diagnosis of vascular disease. The Board does note that a June 1968 service treatment record documented shooting left lateral thigh and leg pain; however, there was a notation of lower back trauma at that time. There is also not evidence showing that the Veteran had vascular disease shortly after his separation from service or for many years thereafter. He did not assert otherwise. In addition to the lack of evidence showing that vascular disease manifested during active service or within proximity thereto, the weight of the evidence of record does not link the Veteran’s current disorder to his military service. In an October 2000 VA treatment note, the Veteran complained of pain in his left leg and cramps in his feet that began six months ago, but had increased in the past four weeks. He indicated that he was a long-haul truck driver and that his leg bothered him when he pushed on the clutch a lot. The diagnosis was possible peripheral vascular disease, nothing acute. In a November 2000 VA surgical consultation for left calf pain, the Veteran reported that he had difficulty walking more than one block. He stated that he worked as a truck driver. An examination showed a slight clonus of the left foot compared with the right. The diagnosis was probably peripheral vascular occlusive disease. A November 2000 VA treatment note documented recent extreme increasing claudication of the left lower extremity with intermittent coolness of the left foot. It was noted that the Veteran likely had quite progressed vascular disease and that noninvasive doppler studies indicated possible iliac artery occlusion. A September 2001 VA treatment note documented a diagnosis of peripheral vascular disease with left side aortofemoral bypass surgery in January 2001. In March 2003 and July 2003 VA treatment notes, the Veteran was diagnosed with peripheral vascular disorder, status-post aortofemoral bypass surgery in 2001. In a September 2005 VA treatment note, the Veteran reported that he developed numbness below the waist following an operation for peripheral vascular disease in 2001. During a February 2004 VA vascular doppler arterial consultation, the Veteran’s symptoms were recorded as burning in both feet and legs following an aortofemoral bypass surgery in January 2001. During an October 2005 VA neurology consultation, the Veteran complained of pain in his legs and hips that had been present for the past two to three years. He related that the pain started acutely following an aortobifemoral bypass in 2001. He described having constant burning pain involving both of his legs, mostly in the anterior portions. The neurologist noted that the Veteran was 57 years-old and that he had hypertension, high cholesterol, two myocardial infarctions, and status-post aortobifemoral bypass in 2001. The neurologist stated that a physical examination appeared to show that the Veteran had a distal lower extremity large fiber sensory neuropathy, but that it did not explain the burning pain. The neurologist indicated that the Veteran would be worked up for any nerve damage associated with the burning discomfort in his legs. In an October 2005 VA addendum note, the Veteran’s history of aortobifemoral bypass was documented in January 2001. It was noted that he developed burning pain over his anterior thigh down the shin and anterior foot following the bypass. Prior to surgery, he complained of achy pain from his bilateral thighs to his feet precipitated by walking associated with lower extremity weakness. Since the surgery, the Veteran reported that the achy pain had improved, but it still occasionally occurred at the thighs. He also related that he developed a burning pain from the anterior thigh down to the shin and anterior aspect of the foot. The neurologist reported that an examination revealed an early distal lower extremity predominantly axonal sensory polyneuropathy likely vascular in nature. He also noted that there was no clear etiology for the burning sensation. An October 2005 VA EMG/NCS testing study was mildly abnormal. There was evidence of an early distal lower extremity predominantly axonal sensory polyneuropathy likely vascular in nature. However, the neurologist again noted that this did not explain the proximal burning sensation, which had no electrodiagnostic correlate at the time. In addition, he noted that there was no evidence of myopathy or radiculopathy. In a January 2016 VA artery and vein conditions examination, the VA examiner noted that the Veteran was diagnosed with peripheral vascular disease in both legs since 2000. During the examination, the Veteran reported that he had bilateral leg circulation problems since 2000. He related that he had aortofemoral bypass surgery in January 2001 and that his leg pain and claudication had been getting worse. The Veteran stated that he was diagnosed with hypertension in 1992 and that he was diagnosed with hyperlipidemia in that timeframe. He also indicated that he smoked one to one and a half packs of cigarettes per day for 40 years. He stated that he was diagnosed with diabetes mellitus in 2008. In the January 2016 VA medical opinion, the VA examiner opined that the Veteran’s peripheral vascular disease or peripheral arterial disease was less likely than not incurred in or caused by service. The examiner noted that the Veteran had no complaints or diagnoses of peripheral vascular disease or peripheral arterial disease. The examiner also indicated that peer-reviewed medical literature did not show enough study to support the cause and effect relationship between peripheral vascular disease or peripheral arterial disease and military service. The examiner also opined that the Veteran’s service-connected ischemic heart disease had no contribution to the cause or aggravation of peripheral vascular disease or peripheral arterial disease. The examiner explained that approximately 20 percent of adults older than 55 years-old have peripheral vascular disease or peripheral arterial disease, although estimates of the prevalence varied widely. The examiner stated that a large study conducted in the United States from 1999 to 2000 estimated that approximately five million community-dwelling Americans are diagnosed with peripheral artery disease versus peripheral vascular disease with the number expected to increase to seven million by 2010. The examiner reported that the prevalence of peripheral vascular disease or peripheral arterial disease increased substantially with age and that other risk factors included smoking, hyperlipidemia, hypertension, and diabetes mellitus. The examiner reasoned that the Veteran’s peripheral vascular disease or peripheral arterial disease was multifactorial, to include, more likely, his age, long-standing history of smoking, and long-standing hypertension, hyperlipidemia, and diabetes mellitus. The examiner indicated that the specific weight of the risk factors could not be measured. The Board finds the January 2016 VA examiner’s opinion is highly probative. The examiner provided a thorough medical opinion that is based on an accurate factual premise and supported by rationale. The Board acknowledges the Veteran’s lay statements that his service-connected ischemic heart disease caused or aggravated his peripheral vascular disease. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of peripheral vascular disease falls outside the realm of common knowledge of a lay person, particularly given that a diagnosis of peripheral vascular disease requires objective testing, there was a delayed onset of the disorder, and there were multiple risk factors present in this case. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Moreover, even assuming the Veteran’s lay assertions regarding etiology are competent, the Board nevertheless finds the January 2016 VA examiner’s opinion to be more probative, as it was provided by a medical professional with knowledge, training, and expertise and is supported by a complete rationale based on such knowledge and medical literature. The examiner also reviewed the claims file and considered the Veteran’s reported history and lay statements. For the reasons outlined above, the Board concludes that the weight of the evidence is against a finding of entitlement to service connection for peripheral vascular disease. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Arthritis In considering the evidence of record under the laws and regulations, the Board finds that service connection for arthritis of the hips, legs, and back is not warranted. The Veteran’s service treatment records are negative for any complaints or diagnoses of arthritis. The Board does note that a June 1968 service treatment record documented shooting left lateral thigh and leg pain with a notation of lower back trauma. However, there was no x-ray evidence of arthritis during service or for many years thereafter. In addition to the lack of evidence showing that arthritis manifested during active service or within proximity thereto, the weight of the evidence of record does not link the Veteran’s claimed arthritis to his military service. The Veteran was afforded VA hip and thigh conditions, knees and lower leg conditions, and back conditions examinations in January 2016. The January 2016 VA examiner opined that the Veteran’s claimed arthritis was less likely than not incurred in or caused by service. Regarding a back disorder, the VA examiner noted that the Veteran complained of sharp and shooting left leg and hip pain with trauma to the back during service in June 1968. The impression at that time was to rule out a disc condition, and a lumbosacral x-ray was recommended. However, subsequent lumbosacral spine x-rays dated in June 1968 were normal. The January 2016 VA examiner noted that he believed that the in-service condition was acute and self-limited. He observed that the Veteran did not have chronic back, hip, or leg disorder treatment in service. He opined that the Veteran’s degenerative disc disease and degenerative joint disease of the hips were more likely from his heavy-duty civilian job after he left service, as well as part of generalized degeneration due to age. In addition, the VA examiner noted that, on examination and x-rays, both of the Veteran’s knees were normal. The Veteran and the appellant did not submit or identify any evidence of a currently diagnosed condition related to bilateral knee disorders for which service connection may be granted. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Because the evidence shows that the Veteran has not had a current disability related to bilateral knee disorders during the pendency of the appeal, the Board concludes that service connection is not warranted, and no discussion of the remaining elements is necessary. See Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006) (the absence of any one element will result in denial of service connection). With respect to the Veteran’s low back and hip disorders, the January 2016 VA examiner opined that the Veteran’s degenerative disc disease and degenerative joint disease of the hips were more likely from his heavy duty civilian job after he left service, as well as part of generalized degeneration due to age. The Board finds the January 2016 VA examiner’s opinion is highly probative. The examiner provided a thorough medical opinion that is based on an accurate factual premise and supported by rationale. The Board acknowledges the Veteran’s lay statements that his back and hip arthritis were caused by service. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of arthritis falls outside the realm of common knowledge of a lay person, particularly given the fact that a diagnosis of arthritis requires objective testing and was not diagnosed until many years later. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Moreover, even assuming the Veteran’s lay assertions regarding etiology are competent, the Board nevertheless finds the January 2016 VA examiner’s opinion to be more probative, as it was provided by a medical professional with knowledge, training, and expertise and is supported by a complete rationale based on such knowledge and medical literature. The examiner also reviewed the claims file and considered the Veteran’s reported history and lay statements. As the preponderance of the evidence is against the claim for service connection for arthritis of the hips, legs, and back, the benefit-of-the-doubt rule does not apply, and the claim must be denied. See 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Conclusion The appellant has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 368 (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). REASONS FOR REMAND The Veteran was granted entitlement to TDIU effective from January 1, 2010, but the issue remains on appeal prior to that date. As the Board has granted higher initial evaluation for IHD and PTSD prior to January 1, 2010, the AOJ must effectuate those grants. Moreover, in the October 2015 remand, the Board directed the AOJ to obtain a VA social and industrial survey (field examination) to ascertain the impact of the Veteran’s service-connected disabilities on his ability to work. However, it does not appear that the Veteran was provided an examination. Therefore, on remand, the claims file should be referred to an appropriate examiner for an opinion as to the impact of the Veteran’s service-connected disabilities on his ability to work prior to January 1, 2010, and to ensure compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter is REMANDED for the following action: 1. The AOJ should effectuate the higher initial evaluations granted herein. 2. The AOJ should obtain a VA medical opinion to ascertain the combined impact of the Veteran’s service-connected disabilities on his ability to work prior to January 1, 2010. It should be noted that the Veteran was only service-connected for PTSD and IHD prior to that date. The report should indicate how the Veteran’s service-connected disabilities alone affected his employability prior to January 1, 2010. The report should also indicate if there was any form of employment that the Veteran could have performed prior to January 1, 2010, and if so, what type. A written copy of the report should be associated with the claims file. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Osegueda, 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.