Citation Nr: 21023187 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 11-07 519 DATE: April 20, 2021 ORDER An initial rating in excess of 50 percent for an acquired psychiatric disorder, characterized as Posttraumatic Stress Disorder (PTSD) and major depression, prior to June 25, 2019, and in excess of 70 percent, thereafter, is denied. Entitlement to a rating in excess of 20 percent for a low back disability, characterized as lumbar strain, is denied. Entitlement to service connection for a vestibular disorder, diagnosed as vertigo, is granted. Entitlement to service connection for Traumatic Brain Injury (TBI) residuals is granted. Entitlement to service connection for a left hip disorder, characterized as avascular necrosis, to include as secondary to a service-connected low-back disability, is denied. Entitlement to a left knee disorder, characterized as degenerative joint disease post knee replacement, to include as secondary to a service-connected low-back disability, is denied. REMANDED Entitlement to an effective date earlier than April 25, 2011, for the grant of a total disability rating based on individual unemployability (TDIU), is remanded. FINDINGS OF FACT 1. Prior to June 25, 2019, the Veteran’s acquired psychiatric disorder was characterized by occupational and social impairment with reduced reliability and productivity due to such symptoms as: depressed mood, anxiety, sleep impairment, mild memory loss, mood disturbance, difficulty in adapting to stressful circumstances and maintaining effective work and social relationships; occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood was not shown. 2. Since June 25, 2019, the Veteran’s acquired psychiatric disorder was characterized by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to symptoms such as: depressed mood, anxiety, anxiety, sleep impairment, mild memory loss, circumlocutory or stereotyped speech, difficultly in understanding complex commands, difficulty in establishing and maintaining effective work and social relationships and adaptation to stress circumstances. A total social and occupational impairment has not been shown. 3. During the period on appeal, the Veteran’s low back disability has been manifested by pain and limitation of motion; forward flexion of the thoracolumbar spine less than 30 degrees, and/or favorable ankylosis of the entire thoracolumbar spine, have not been shown. 4. The preponderance of the evidence indicates that his vestibular disorder, diagnosed as vertigo, is related to his active duty service and combat experience. 5. The evidence is at least in equipoise as to whether the Veteran suffered a TBI during active duty service. 6. The Veteran’s left hip disorder, characterized as avascular necrosis, was not shown in service or for many years after separation, and is otherwise not related to the Veteran’s active duty service, to include as secondary to a service-connected disability. 7. The Veteran’s left knee disorder, characterized as degenerative joint disease post knee replacement, was not shown in service or for many years after separation, and is otherwise not related to the Veteran’s active duty service, to include as secondary to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 50 percent for an acquired psychiatric disability, characterized as Posttraumatic Stress Disorder (PTSD) and major depression, prior to June 25, 2019 have not been met. 38 U.S.C. §§ 1154 (a), 1155, 5107(b) 1155; 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to an initial rating in excess of 70 percent for an acquired psychiatric disability, characterized as Posttraumatic Stress Disorder (PTSD) and major depression, since June 25, 2019 have not been met. 38 U.S.C. §§ 1154 (a), 1155, 5107(b) 1155; 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411. 3. The criteria for an initial rating in excess of 20 percent for a low back disability, characterized as lumbar strain, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5237. 4. The criteria for entitlement to service connection for a vestibular disorder, diagnosed as vertigo, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for entitlement to service connection for Traumatic Brain Injury (TBI) residuals, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for Entitlement to service connection for a left hip disorder, characterized as avascular necrosis, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 7. The criteria for Entitlement to a left knee disorder, characterized as degenerative joint disease post knee replacement, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1969 to January 1972. These matters return to the Board of Veterans’ Appeals (Board) following the issuance of Board remands in February and August 2019 which directed the Regional Office (RO) to undertake and complete additional development. Additionally, the Veteran’s claims have been subject to Joint Motion for Remand decisions in April 2016 and May 2018. INCREASED RATINGS The Veteran is seeking increased ratings for his service-connected acquired psychiatric and low back disabilities. Specifically, he alleges that the disability ratings assigned for the periods on appeal do not adequately contemplate their severity. Disability evaluations are determined by applying a schedule of ratings which is based on average impairment of earning capacity based on the specific diagnostic codes identifying the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). When determining the appropriate disability evaluation to assign, the Board’s “primary consideration” is the Veteran’s symptoms. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). For musculoskeletal disabilities, a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. 38 C.F.R. §§ 4.10, 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and therefore, actually painful, unstable, or malaligned joints, due to healed injury, are as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. 1. An initial rating in excess of 50 percent for an acquired psychiatric disorder, characterized as Posttraumatic Stress Disorder (PTSD) and major depression, prior to June 25, 2019, and in excess of 70 percent thereafter, The Veteran’s acquired psychiatric disability has been assigned a rating of 50 percent under 38 C.F.R. § 4.130, DC 9411 for the period prior to June 25, 2019, and a rating of 70 percent thereafter. In order to warrant higher ratings, the evidence must demonstrate: • 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 worklike setting); inability to establish and maintain effective relationships (70 percent); • 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 (100 percent). 38 C.F.R. § 4.130, DC 9411. After a review of the evidence of record, the Board determines that higher ratings are not warranted for any period on appeal. Indeed, while the Veteran has occasional symptoms that could support a higher rating, the Veteran’s symptoms on balance did not otherwise cause occupational and social impairment in most areas during the period prior to June 25, 2019, or total occupational and social impairment thereafter. Prior to June 25, 2019 As an initial matter, the Veteran was afforded VA examinations in June 2008 and 2012. At the June 2008 examination the Veteran was noted to be nice, polite but somewhat anxious. He was noted to be well dressed and groomed. The examiner noted that he exhibited good social skills and fluid speech. He was well-oriented to all spheres and his affect was spontaneous and showed good reasoning. The examiner noted symptoms such as panic attacks, depression, anxiety, sleep problems, disturbances of mood, and anger outbursts, he denied any psychotic symptoms and denied any homicidal and/or suicidal ideation. Overall, the examiner declined to diagnose the Veteran with PTSD or any other psychiatric disorder and indicated that his reported symptoms did not result in functional impairment. Next, the June 2012 examiner endorsed diagnoses for both PTSD and major depression. At this examination, the Veteran reported that he felt his symptoms had worsened including his depression, sleep impairment, anxiety, and memory loss. He also reported more feelings of anger and indicated that he spends most of his time isolated in his bedroom. The Veteran was noted to be clean and well groomed. He was polite and cooperative; however, his mood was listed as depressed with matching affect. His thought processes were clear, linear, coherent, and goal oriented. He reported fear over his perceived loss of memory and reported that he attends a PTSD support group every Wednesday. The Veteran denied delusions, hallucinations, and suicidal and homicidal ideation. Overall, the examiner determined that the Veteran’s symptoms manifested in occupational and social impairment with occasional decrease in work efficiency and intermitted periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. The Veteran’s medical records from the period prior to June 25, 2019, including from January 2015, April 2015. October 2016, and April 2017 are silent for any symptoms concurrent with a rating in excess of 50 percent. Additionally, there were no indications that the Veteran experienced symptoms concurrent with occupational and social impairment in most areas, such as: hallucinations; delusions; persistent danger of hurting himself or others; and no grossly inappropriate behavior or impairment in thought. In view of these clinical evaluations, the Board finds that the Veteran does not exhibit objective symptomatology that would be sufficient to warrant a rating in excess of 50 percent for the period prior to June 25, 2019. Specifically, the Board finds that there is not sufficient evidence that the Veteran’s symptoms are of the severity and frequency to cause the level of occupational and social impairment associated with a higher disability rating during the period on appeal. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). Next, the Board has also considered the extent to which there are other indications of occupational and social impairment with deficiencies in most areas such as obsessional rituals which interfere with routine activities, speech intermittently, illogical obscure, or irrelevant near-continuous panic or depression affecting the ability to function independently. See Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). In this regard, while the Veteran’s disorder reflects a moderate overall impact on his social and occupational functioning, he does not have occupational and social impairment in most areas. Specifically, while the Veteran has reported feelings of sadness and anger, he nevertheless maintains a close relationship with his wife and granddaughter whom he lives with, has some close friends, and has attended a PTSD support group for a decade. Therefore, on balance, he did not display the “inability” to establish and maintain effective relationships, even when factoring in other relevant criteria outside of the rating code. Mauerhan, 16 Vet. App. 436, 444. The Board has also considered the Veteran’s Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). GAF scores from 31 through 40 contemplate some impairment in reality testing or communication (e.g., speech at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score of 41-50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g. no friends, unable to keep a job) while a GAF score of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or coworkers). Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV, including the use of GAF scores. However, as the period on appeal partially pre-dates the amendment, the Board must continue to consider the criteria contained in the DSM-IV. See 38 C.F.R. § 4.126 (a). In June 2007, the Veteran’s GAF score was 45. His GAF score increased to 48 in September 2007. In April 2009 his GAF score had rebounded to 70. By April 2012, it had decreased again to 60. While the Veteran’s GAF scores in June and September 2007 are no doubt serious and potentially reflect heightened symptoms during that time, they are not overall reflective of the Veteran’s occupational and social impairment due to his PTSD during this time. In fact, his scores were never noted to be below 60 following this short four-month period in 2007. Additionally, shortly after this period, the Veteran began to attend a PTSD support group and his GAF scores increased when they were measured. Here, the Board finds that a GAF score in the range of 45-48 may be consistent with the symptoms the Veteran displayed during the period of June to September 2007, they are not otherwise indicative of his average symptoms during the period prior to June 25, 2019. His level of impairment during the vast majority of this period does not constitute occupational and social impairment with deficiencies in most areas. In that regard, after a review of the record and consideration of the evidence, the Board finds that a grant of a rating in excess of 50 percent for the Veteran’s acquired psychiatric disability would be unwarranted, as the granted ratings most closely reflect the manifested severity and symptoms during the period prior to June 25, 2019. From June 25, 2019 The Veteran was afforded a VA examination in June 2019 which led to the increase of his disability rating to 70 percent. The Veteran was noted to be appropriately dressed and groomed, he was also alert and oriented to all spheres. He was noted to be anxious, sad, and irritable. His speech was hesitant but otherwise normal. There was some evidence noted for short-term memory difficulties. The Veteran’s concentration and focus were hampered by affective flooding. The Veteran’s symptoms were noted to include depression, hypervigilance, irritability, slow reactions, and increased distractibility. There were no hallucinations or delusions noted. Suicidal and/or homicidal ideation was not noted. Overall, the examiner noted that the Veteran’s symptoms manifested in Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran’s medical records from this latest period on appeal are silent for any indication of symptoms concurrent with total occupational and social impairment. Indeed, at the June 2019 VA examination the Veteran reported attending a PTSD support group continuously over the past decade. He also indicated that he had stopped taking medication prescribed for his psychiatric disability, there was no indication from the examiner that this caused an increase in the severity of his symptoms. The Veteran also described methods employed by himself and his wife to reduce his exposure to stress and triggering events. His medical records, including from March 2020, do not reflect an increase in the severity of his symptoms and there are no reports of homicidal or suicidal ideation, and in fact he reported that he was sleeping well. In view of these clinical evaluations, the Board finds that the Veteran does not exhibit objective symptomatology that would be sufficient to warrant a rating in excess of 70 percent for the period since June 25, 2019. Specifically, the Board finds that there is not sufficient evidence that the Veteran’s symptoms are of the severity and frequency to cause the level of occupational and social impairment associated with a higher disability rating during the period on appeal. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). Next, the Board has also considered the extent to which there are other indications of occupational and social impairment with deficiencies in most areas such as obsessional rituals which interfere with routine activities, speech intermittently, illogical obscure, or irrelevant near-continuous panic or depression affecting the ability to function independently. See Mauerhan, 16 Vet. App. 436, 444 (2002). In this regard, while the Veteran’s disorder reflects a severe overall impact on his social and occupational functioning, he does not have total occupational and social impairment. Specifically, while the Veteran’s medical records reflect that his feelings of depression, anger, some paranoia, and anxiety, he nevertheless maintained a close relationship with his family who he has noted as supportive, and he goes to his PTSD support group regularly. Therefore, on balance, he does not display total social and occupational impairment, even when factoring in other relevant criteria outside of the rating code. Mauerhan, 16 Vet. App. 436, 444. In that regard, after a review of the record and consideration of the evidence, the Board finds that a grant of a rating in excess of 70 percent for the Veteran’s acquired psychiatric disability would be unwarranted, as the granted ratings most closely reflect the manifested severity and symptoms during the period since June 25, 2019. Other Considerations In considering the appropriate disability ratings, the Board has also considered the statements from the Veteran, his wife, family members, and a former colleague that his service-connected acquired psychiatric disability is worse than the ratings he assigned to either period on appeal. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. While the various parties to the submitted statements are competent to report symptoms of the Veteran’s acquired psychiatric disability, such as feelings and expression of sadness, irritability, anxiety or paranoia, as this requires only personal knowledge as it comes to them through their senses, they are not competent to identify a specific level of disability of the Veteran’s psychiatric symptoms according to the appropriate diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). On the other hand, such competent evidence concerning the nature and extent of the Veteran’s service-connected acquired psychiatric disability has been provided by the medical personnel who have examined him during the appeal period and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which his disabilities are evaluated. Therefore, given the aforementioned evidence, the Board finds that the Veteran’s current symptoms of his acquired psychiatric disability do not warrant an initial rating in excess of 50 percent during the period prior to June 25, 2019, or in excess of 70 percent thereafter, as such, the Veteran’s claim is denied. 2. Entitlement to a rating in excess of 20 percent for a low back disability, characterized as lumbar strain. The Veteran’s low back disability is rated at 20 percent under Diagnostic Code (DC) 5237, which addresses strain of the lumbar or cervical portions of the spine. Under DC 5237, a rating in excess of 20 percent is warranted when the evidence shows: • Forward flexion of the thoracolumbar spine to 30 degrees or less (40 percent); or, • Favorable ankylosis of the entire thoracolumbar spine (40 percent). 38 C.F.R. § 4.71a. Based on the evidence of record, the Board determines that a rating in excess of 20 percent is not warranted. The Veteran was afforded VA examinations in August 2006, June 2012, January 2014, and April 2018 to evaluate the severity of the Veteran’s low back disability. An addendum opinion was procured in June 2019. At the August 2006 examination, the Veteran reported chronic low back pain and radiating left leg pain. He noted that he treats his pain with Vicodin. He also indicated that his pain increases with activity, but flare-ups were not endorsed. Upon examination the Veteran’s forward flexion was measured to 110 degrees, his combined range of motion was measured at 250 degrees. The Veteran’s gait was noted to be normal, and there was no documented instability or weakness. The examiner did not indicate the presence of ankylosis, or any other associated neurological disorder related to the Veteran’s low back disability. Similarly, at the June 2012 examination the Veteran reported back pain and left leg tingling, he indicated that his low back symptoms are treated fairly well with gabapentin. The Veteran affirmatively denied any foot drop, dragging, or flare-ups. The examiner noted that there were no signs of myelopathy or cauda equine, and no signs of neurogenic claudication; there were no changes in bowel or bladder control. Upon examination, the Veteran displayed full flexion and full combined range of motion. The examiner documented pain on motion beginning at 45 degrees of forward flexion; pain on palpation and/or tenderness was not found. The Veteran displayed full muscle strength and intervertebral disc syndrome (IVDS) was not diagnosed, however, the examiner did endorse a diagnosis of left lower extremity radiculopathy of a mild severity. Next, at the January 2014 examination, the Veteran reported ongoing low back pain and left leg radicular pain and tinging. He indicated increased pain with bending, lifting, prolonged walking, standing, and sitting, which he treats with muscle relaxers and gabapentin. He affirmatively denied any incidence of flare-ups. On examination, the Veteran displayed full forward flexion and full combined flexion with pain beginning at 50 degrees of forward flexion. Repetitive testing did not show any decrease in range of motion. The examiner noted that the Veteran’s low back disability caused less movement than normal, painful movement, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. The examiner noted that the Veteran had lumbar muscle tenderness, however, the Veteran also had full muscle strength. The Veteran’s left lower extremity radiculopathy was noted to have a mild severity. The examiner did not find ankylosis, and IVDS was not endorsed. No other neurological abnormalities or diagnoses were found by the examiner. Finally, the Veteran was examined in April 2018. He reported pain, and occasional radiation of radicular pain to his left leg. He indicated that he could walk on average of 200 yards without needing to stop, and that he treats his pain with several medications including morphine, hydrocodone, acetaminophen, gabapentin, and meloxicam, and employs the use of stretching exercises each morning. The Veteran denied flare-ups. Upon examination, the Veteran’s forward flexion was measured to 90 degrees and his combined range of motion was 180 degrees. The examiner did not perform repetitive use testing but indicated that the examination was medically consistent with the Veteran’s statements describing his functional loss with repetition. The examiner did not endorse muscle spasm, IVDS, or ankylosis, and displayed full muscle strength. The examiner did not find or endorse diagnoses for any additional neurological abnormalities. In June 2019, the RO sought an addendum opinion, as directed by a Board remand, to evaluate the Veteran’s potential range of motion loss due to suspected flare-ups. The examiner noted that the Veteran had never claimed flare-ups and in fact affirmatively denied them. While the Veteran indicated that he experienced increased pain with some activities, there was no indication that this caused additional loss of functional use. In fact, the Veteran’s past VA examinations showed that he was able to engage in repetitive use without additional functional loss even when pain was documented. The examiner did not opine as to functional loss as flare-ups have never been endorsed by the Veteran and there is no objective evidence to support their existence in this case. There was also no evidence in the Veteran's treatment records during this period, including from August 2011 and June 2016, to support a rating in excess of 20 percent based upon limitation of motion. Therefore, a rating in excess of 20 percent is not for application. Other Considerations When considering these ratings, the Board has considered the impact of functional loss in the Veteran's back due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 206 -07 (1995). In this case, the Veteran has complained that he is limited in performing activities of daily living due to pain. However, while the Veteran experiences the aforementioned symptoms, overall, it does not appear that these symptoms result in additional and significant functional loss, and him complaints are adequately contemplated in the ratings he currently receives. See Sharp v. Shinseki, 29 Vet. App. 26 (2017); Mitchell v. Shinseki, 25 Vet. App. 32, 37-43 (2011) (pain must affect some aspect of the normal working movements of the body such as strength, speed, coordination, or endurance). Moreover, the Veteran has affirmatively denied any incidence of flare-ups. Here, while the Veteran has alleged that he is functionally limited due to his lumbar disability, his medical records and his VA examinations are silent for any discussion of him being limited to the extent that would indicate that a higher rating is warranted. Next, when evaluating the extent of the Veteran's low back disability, the Board is required to consider whether a separate evaluation is warranted for any associated neurological abnormality including, but not limited to, bowel or bladder impairment, neurological impairment in the extremities or other such disorders, which are to be evaluated under the appropriate diagnostic code. See 38 C.F.R. § 4.71 (a). In this case, the medical evidence indicates diagnoses for left lower extremity radiculopathy for which the Veteran is currently service connected for at 10 percent under DC 8520. A higher rating under DC 8520 is provided when the radicular disability is manifested by moderate incomplete paralysis of the sciatic nerve. See 38 C.F.R. § 4.71 (a) DC 8520. The Veteran has not alleged an increase in the severity of this disability, nor does the evidence support such a finding. His left lower extremity radiculopathy has only ever been determined to be of a mild severity. As such, a higher rating will not be assigned. Aside from the Veteran’s left lower extremity radiculopathy, he has not been found to have any other associated neurological abnormality and as such, additional ratings for those disorders will not be considered. The Board acknowledges the assertions and belief from the Veteran and his wife that his low back disability has progressed beyond its original diagnosis and thus his ratings should be increased. Nevertheless, while he is competent to report the observable physical symptoms of this disorder, such as pain, he is not competent to determine that it has progressed. This issue is medically complex and requires specialized medical education and knowledge of the interaction between multiple systems in the body as well as the ability to interpret complicated diagnostic medical testing. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007), See 38 U.S.C. § 1110. On the other hand, such competent evidence concerning the nature and extent of the Veteran's low back disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which this disability is evaluated. Competency of evidence differs from weight and credibility. While the Veteran and his wife are competent to report symptoms because this requires only personal knowledge as it comes to them through their senses, they are not competent to identify a specific level of disability of his low back disability according to the appropriate diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Accordingly, based on the evidence of record, a higher initial rating for the Veteran’s low back disability is not warranted for the period on appeal. The Veteran's appeal is denied. SERVICE CONNECTION Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). In addition to the regulations cited above, service connection may be established for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. In cases where a Veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C. § 1154 (b) and its implementing regulation, 38 C.F.R. § 3.304 (d), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of in-service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C. § 1154 (b); 38 C.F.R. § 3.304 (d). To establish service connection, however, there must be evidence of a nexus between the current disability and the combat injury. See Dalton v. Nicholson, 21 Vet. App. 23, 36-37 (2007); Libertine v. Brown, 9 Vet. App. 521, 523-24 (1996); Reeves v Shinseki, 682 F.3d 988 (Fed. Cir. 2012). 1. Entitlement to service connection for a vestibular disorder, diagnosed as vertigo. 2. Entitlement to service connection for Traumatic Brain Injury (TBI) residuals. The Veteran is claiming entitlement to service connection for a vestibular disorder, which has been diagnosed as vertigo, and for TBI residuals. Initially, the Board must evaluate whether the Veteran is entitled to the application of 38 U.S.C. § 1154 (b), which allows for presumption of an in-service injury in cases where the Veteran is engaged with an enemy combatant. In this instance, the Veteran asserts that these disorders were caused by a 20-foot fall from a guard tower during a mortar attack while he was stationed in Vietnam in 1971. The Veteran’s second DD-214 indicates that the Veteran was stationed in Vietnam and he received the Vietnam Service Medal with Bronze Service Star and Vietnam Combat Medal. Thus, his combat experience is not in dispute. Therefore, the Board finds that the Veteran should be considered a combat veteran under 38 U.S.C. § 1154(b) with respect to the underlying events relating to his TBI residuals and vertigo, even without a formal diagnosis. A September 2019 VA examiner opined that the Veteran’s vertigo was at least as likely as not related to his active duty service. The examiner noted that such a fall would have resulted in a concussion and noted that the Veteran is reported to have lost consciousness. They further elaborated that the diagnosis of such a disorder would have been elusive in the period between 1970 and 2000, and only recently had a doctor diagnosed and began treatment for the Veteran. Moreover, the Veteran was not found to have any marked deformities or abnormalities of his inner ear. The Veteran was also afforded VA examinations in October 2019 March 2020 to evaluate his TBI residuals claim. Both examiners opined that the Veteran did not have a diagnosis of a TBI or residuals. The October 2019 examiner noted the September 2019 opinion and indicated disagreement as the conclusions were based upon the assumption that the Veteran suffered a concussion following the mortar attack. Moreover, this examiner relied solely on the medical records in finding that there was no indication that the Veteran suffered a concussion. However, the Board notes that the Veteran reported that he was not treated following the attack as he was needed for repair work. The March 2020 examiner indicated that both vertigo and TBI residuals were less likely than not related to active service and primarily citied the length of time between the Veteran’s service and the incidence of his Vertigo in his medical records. The examiner indicated that symptoms would have begun shortly after the attack and that there was no medical evidence to substantiate. However, there is no indication that the examiner considered the Veteran’s lay statements in forming their opinion. The Board finds that the Veteran should be service connected for his claimed vestibular disorder, diagnosed as vertigo, and for his claimed TBI residuals. The Veteran has a formal diagnosis for vertigo, and the Board is convinced by his lay testimony that it can be traced to the 1971 mortar attack. While the Veteran has not received a formal diagnosis of TBI residuals, the Board is convinced by his lay testimony that he indeed suffered a TBI at the time of the 1971 mortar attack and fall based upon his recitation and has experienced residual symptoms. The Board finds that the negative and positive evidence is at least in equipoise as to whether the Veteran suffered a TBI while in service. As such, the Veteran’s claims for service connection for vertigo and TBI residuals are granted. 3. Entitlement to service connection for a left hip disorder, characterized as avascular necrosis, to include as secondary to a service-connected low-back disability. 4. Entitlement to a left knee disorder, characterized as degenerative joint disease post knee replacement, to include as secondary to a service-connected low-back disability. The Veteran is claiming service connection for left hip and knee disorders which he attributes as secondary to his service-connected low back disability. After a review of the evidence, the Board finds that these claims must be denied. As an initial matter, the Veteran’s service treatment records are silent for any signs, symptoms, treatment, or diagnosis of a chronic disorder of either the left hip or left knee. In fact, the Veteran first received diagnoses of knee and hip disorders in 2007 and 1997 respectfully. The Board notes that the Veteran has never asserted that either of these claimed disorders began during active duty service or within one year of his separation. As such, service connection via a direct relationship to a disease or injury in-service injury is not available for these disorders. 38 U.S.C. § 1110. Additionally, given the large gap of time between service and his diagnoses continuity of symptoms has not been shown based on the clinical evidence, as there is no indication of symptoms or a diagnosis within one year of the Veteran’s separation from service and he has not claimed so, including for purposes of the chronic disease presumption under 38 C.F.R. § 3.307 (a)(3). Importantly, the Board notes that the Veteran was afforded a VA examination in March 1972 for his back, at which he did not indicate any signs or symptoms of a knee or hip disorder. Importantly, the Board notes that the Veteran is a combat Veteran and the Board must evaluate whether the Veteran is entitled to the application of 38 U.S.C. § 1154 (b), which allows for presumption of an in-service injury in cases where the Veteran is engaged with an enemy combatant. In this instance, the Veteran has denied any injury in service directly to his left knee or left hip. Moreover, his claims for service connection for these disorders have consistently been predicated on the theory that they are as a result of another service-connected disability, namely his low back disability. Even if the Veteran suffered additional injuries in service, there is no evidence of either a chronic knee or hip disorder until the late 1990s and mid-2000s. As these disorders are not claimed to stem directly from the Veteran’s combat experience and there is no evidence to support that theory otherwise, consideration of service connection for these disorders under the combat presumption is not warranted. Next, service connection may nevertheless be established if a relationship between the Veteran’s claimed disorders and another service-connected disability is otherwise demonstrated by sufficient competent evidence, including medical evidence and opinions. To this end, the Veteran was afforded VA examinations to determine the nature and etiology of his left hip and knee disorders in January 2013 (solely for his left knee), March 2019, and December 2019. The RO sought an addendum opinion in April 2019 for an opinion on the potential secondary cause and/or aggravation of the Veteran’s left knee disorder by his service-connected low back disability. At the January 2009 examination the Veteran indicated that he had injured his back in a 1971 fall but did not note any knee pain. He generally asserted that after his discharge he eventually had knee pain leading to surgery in the late 1970s. The Board notes that there are no medical records in the Veteran’s case file relating to this surgery. He also indicated that he was told that the fall was likely the cause of the injury. The examiner concluded that the Veteran’s left knee disorder was less likely than not due to service. At the March 2019 left hip examination, the Veteran reported hip pain, which increases with flare-ups and causes impairment when standing or walking. The examiner opined that the Veteran’s left hip disorder was less likely than not caused or aggravated by his low back disability. The examiner stated that there was no evidence of a gait abnormality as a result of the low back disability, or of abnormal stress on the left hip as a result of the low back disability. Instead, the examiner noted that avascular necrosis is much more likely attributable to alcohol abuse, which has been linked to the development of such disorders. Next, the Veteran was examined in March 2019, whereat he reported knee pain and flare-ups which he described as increased pain which results in some difficulty in walking. The examiner opined that the Veteran’s left knee disorder was less likely than not related to active duty service citing the lack of evidence of treatment or complaints by the Veteran of a disorder relating to the left knee. The examiner did not provide an opinion as to the potential relationship between the Veteran’s knee disorder and his low back disability. An addendum opinion was obtained by the RO in April 2019 to address the claim of secondary causation and/or aggravation of the Veteran’s left knee disorder by his low back disability. The examiner opined that it was less likely than not that the Veteran’s left knee disorder was cause and/or aggravated by his low back disability. They indicated that there was no evidence of an affected gait as due to the back disability and that there was no medical literature that supported the idea that a lumbar strain has a direct causative effect on the development of knee pathology. They indicated instead that the most likely cause of the Veteran’s left knee disorder was the natural aging process. At the December 2019 hip examination, the Veteran reported pain and denied flare-ups. The examiner opined that the Veteran’s left hip disorder was less likely than not related to his active duty service or cause and/or aggravated by his low back disability. Regarding the Veteran’s in-service fall, the examiner noted that there were no records which indicate the Veteran was treated for any hip injury, nor has he claimed as much. The examiner noted that the most common risk factors in the development of avascular necrosis are trauma to the bone, and/or alcohol abuse. There was no documented bone trauma in the Veteran’s service treatment records and no indication of a hip disorder before 1997. In discussing the Veteran’s low back disability, the examiner noted that fracture or dislocation may damage the blood vessels in the affected area but that there was no medical basis to suggest that avascular necrosis could result for compensation due to the low back disability, and that there was no evidence of a chronic gait abnormality or a Trendelenburg gait resulting from the Veteran’s low back disability. At his December 2019 left knee examination, the Veteran reported pain and denied flare-ups. The examiner noted that the Veteran’s service treatment records, including his separation examination were silent for any knee disorders. And indicated that any potential knee injury in-service would have been acute and transitory and would have resolved long ago. They indicated that the Veteran’s knee disorder was less likely than not related to his active duty service and was much more likely due to genetic components and/or the aging process. In discussing the Veteran’s left knee disorder as potentially related to his low back disability, the examiner noted that there was no chronic gait abnormality or Trendelenburg gait resulting from compensation due to the Veteran’s low back disability. Finding it less likely than not that the Veteran’s left knee disorder was caused and/or aggravated by his low back disability, and instead, that it was likely due to genetic factors and/or the aging process. The Board also acknowledges the July 2009 private opinion submitted by Drs. S.P. and J.B. who opined that the Veteran’s left hip and knee disorders were cause by compensation from his service-connected low back disability. They indicated that trauma of any kind can cause a lot of unforeseen problems. The Board assigns this opinion little probative weight as there was no indication that the Veteran’s entire medical record was reviewed, and in the intervening time since it was submitted, the VA has obtained multiple opinions addressing the Veteran’s disorders. In rendering this decision, the Board notes and acknowledges the statements from the Veteran and his attorney regarding his belief that his left hip and left knee disorders are caused and/or aggravated via his service-connected low back disability. However, neither the Veteran nor his attorney are not competent to suggest or opine as to the etiology of his left hip and left knee disorders. To diagnose a specific disability and opine as to the etiology of such symptoms requires medical expertise, which they have not been shown to possess. This issue is medically complex and requires specialized medical education and knowledge of the interaction between multiple systems in the body as well as the ability to interpret complicated diagnostic medical testing. See Jandreau v. Shinseki, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Accordingly, the preponderance of the evidence weighs against granting service connection for the Veteran’s left hip and knee disorders. The appeal is denied. 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. REASONS FOR REMAND 1. Entitlement to an effective date earlier than April 25, 2011 for the grant of a total disability rating based on individual unemployability (TDIU) is remanded. The Veteran has submitted a claim requesting an earlier effective date for the grant of a TDIU. As is addressed above, the Board has granted the Veteran’s claims for service connection for both a vestibular disorder, diagnosed as vertigo, and for TBI residuals. Because ratings assigned the result of those grants may have a direct impact on the Veteran’s schedular entitlement to TDIU prior to April 25, 2011, the Board cannot fully address that issue until such ratings are assigned. Therefore, the Board will remand this issue to allow the RO to assign ratings for the issues granted, as ordered above, and reconsider entitlement to TDIU prior to April 25, 2011. The matters are REMANDED for the following action: 1. After the RO has assigned disability ratings for the above granted claims, the RO should readjudicate the Veteran’s claim for an earlier effective date for his TDIU grant. Should his claim remain denied, the RO should issue a Supplemental Statement of the Case to the Veteran and his attorney, and then return the claim to the Board for appellate review. Michael L. Marcum Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Q. Hernan, Attorney Advisor 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.