Citation Nr: 21032769 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-24 764A DATE: May 27, 2021 ORDER Entitlement to service connection for a sleep disorder to include as secondary to service-connected disease or injury is denied. Entitlement to service connection for an arches disability to include as secondary to service-connected disease or injury is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a cervical spine disability to include as secondary to service-connected disease or injury is denied. Entitlement to service connection for headaches to include as secondary to service-connected disease or injury is denied. Entitlement to service connection for a right knee disability to include as secondary to service-connected disease or injury is denied. Entitlement to service connection for a left knee disability to include as secondary to service-connected disease or injury is denied. Entitlement to a 10 percent disability rating for left ankle degenerative joint disease status-post fracture prior to August 12, 2016 is granted; a rating in excess of 10 percent is denied at all times. Entitlement to a disability rating more than 20 percent for internal derangement with degenerative changes of the left shoulder status-post dislocation is denied. FINDINGS OF FACT 1. The Veteran does not have a sleep disorder, nor has he had such disability any time incident to the claim. 2. The Veteran does not have an arches disability, nor has he had such disability any time incident to the claim. 3. The Veteran's right shoulder disability was not manifest in service nor did arthritis of the right shoulder manifest within one year of separation from service. The disability is not otherwise related to service. 4. The Veteran's hypertension was not manifest in service nor did it manifest within one year of separation from service. The disability is not otherwise related to service. 5. The Veteran's cervical spine disability was not manifest in service nor did arthritis of the cervical spine manifest within one year of separation from service. The disability is not otherwise related to service and is unrelated (caused or aggravated) to service-connected disease or injury. 6. The Veteran's left knee disability, knee strain, was not manifest in service; there is no arthritis. The left knee disability is not otherwise related to service and is unrelated (caused or aggravated) to service-connected disease or injury. 7. The Veteran's right knee disability, knee strain, was not manifest in service; there is no arthritis. The right knee disability is not otherwise related to service and is unrelated (caused or aggravated) to service-connected disease or injury. 8. The Veteran's headache disorder was not manifest in service nor did migraines (other organic disease of the nervous system) manifest within one year of separation from service. The disability is not otherwise related to service and is unrelated (caused or aggravated) to service-connected disease or injury. 9. At all times relevant to the decision, to include the period prior to August 12, 2016, left ankle degenerative joint disease status-post fracture is manifested by moderate limited ankle motion; neither marked limitation of motion nor ankylosis was demonstrated or approximated. 10. Internal derangement with degenerative changes of the left (minor) shoulder status-post dislocation is manifested by not more than arm limitation of not more than in excess of midway between side and shoulder level; limitation of motion to 25 degrees from side is not shown or approximated. CONCLUSIONS OF LAW 1. The criteria for service connection for a sleep disorder are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for an arches disability are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a right shoulder disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for cervical spine disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 6. The criteria for service connection for left knee disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 7. The criteria for service connection for right knee disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 8. The criteria for service connection for headaches are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 9. The criteria for a rating of 10 percent for left ankle degenerative joint disease status-post fracture have been met for the period on appeal prior to August 12, 2016; the criteria for a rating in excess of 10 percent have not been met at any time. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5271. 10. The criteria for a rating in excess of 20 percent rating for internal derangement with degenerative changes of the left (minor) shoulder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.59, 4.7, 4.71a, Diagnostic Code 5003-5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1988 to May 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from July 2014 and December 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the record. During the January 2020 Board hearing, the VLJ clarified the issues on appeal; clarified the concept of service connection and increased rating claims; identified potential evidentiary defects; clarified the type of evidence that would support the Veteran's claims; enquired as to the existence of potential outstanding records; and held the record open for 90 days for the submission of additional evidence. Thus, the actions of the VLJ comply with any related duties owed during a hearing set forth in 38 C.F.R. § 3.103. The Board remanded the appeal for necessary development to include obtaining identified non-VA records and updated VA treatment records. The Board also ordered examinations for these conditions except the right shoulder and right knee, finding the current examination record inadequate. Such was accomplished and the matters have been returned to the Board. One of the remanded claims, service connection for Posttraumatic Stress Disorder (PTSD) with Major Depressive Disorder, moderate and Generalized Anxiety Disorder, was granted in full by the RO in February 2021 and is no longer before the Board. Service Connection Veterans are entitled to compensation from VA if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases as will be presumed related to service if they manifested to a compensable degree within a presumptive period following separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection is also warranted for a disability which is proximately due to, aggravated by or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (b). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a); Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). For a medical opinion (i.e., medical evidence) to be given weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Entitlement to service connection for an arches disability to include as secondary to service-connected disease or injury is denied. 2. Entitlement to service connection for a sleep disorder to include as secondary to service-connected disease or injury is denied. The Veteran seeks service connection for an arches disability and a sleep disorder; he reports that he has arch problems related to his in-service duties as an air traffic controller or as secondary to his service-connected left ankle disability. He reports that he has a sleep disorder related to service or as secondary to his service-connected tinnitus. Service treatment records (STRS) are absent complaints of or treatment for a sleep disorder or arches disability. The May 1992 clinical examination at separation was negative for the feet and any report or observation of sleep problems. The Veteran denied frequent trouble sleeping or foot trouble. A January 2021 VA disability benefits questionnaire (DBQ) for psychiatric and sleep problems reflects the examiner's opinion that the Veteran does not meet criteria for a diagnosable sleep condition. The sleep difficulties are symptoms that are attributable to his other diagnosed psychiatric conditions. We note that service-connected PTSD is rated 70 percent disabling and is noted to include sleep impairment symptoms consistent with that rating. A January 2021 DBQ for arches was also accomplished. The examiner found no current arches condition of either the left or right foot. They explained there are no findings, signs and/or symptoms to support a diagnosis. Neither the VA treatment records, nor the non-VA treatment records suggest findings inconsistent with theses DBQs. The issue for the Board is whether the Veteran has current disability that began during service or is at least as likely as not related to an in-service injury or disease or is proximately due to or aggravated by a service-connected disability. The Board concludes that the Veteran does not have current arches or a sleep disorder, and has not had any such disorder at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The competent, credible evidence fails to show current disability. The weight of the evidence is against finding current disability due to disease or injury as to these claims. Due to the absence of credible proof of a current disability due to disease or injury, there is no valid claim for service connection on any basis. Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability at any point during the claim or appeal period. Brammer v. Derwinski, 3 Vet. App. 223 (1992). It follows that there must be a recognized disease or injury. The lay opinion of the Veteran is outweighed by the VA examiner's opinions. The Board acknowledges that he indeed may report his perception of symptoms. These were considered by the VA examiner in rendering the findings of no current disability due to disease or injury. In weighing the evidence, the Board finds that the medical evidence of record, and the lack of credible support for a current disability due to disease or injury, preponderates against the claim. The January 2021 VA examinations are probative, because they are based on an accurate medical history and they provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The medical opinions are the most probative, credible evidence and they show there is no current disability. We accord these medical opinions the most probative weight as to the critical issue of current disability. The Board has considered Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), in which the Federal Circuit held that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity." Id. at 1367-69. We emphasize that under the provisions of 1110, there must be disability and such disability must be due to disease or injury. Although Saunders addressed whether pain could be a disability, Saunders did not eliminate the requirement that there be underlying acquired pathology (disease or injury) in a non-Gulf War case. Here, the appellant had no foreign service. The Board has specifically considered the testimony in this case. However, the VA medical evidence is far more probative in regard to the presence of an underlying pathology (disease or injury) to account for his complaints. The preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine does not apply, and the claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for hypertension is denied. 4. Entitlement to service connection for a right shoulder disability is denied. The Veteran urges that he has hypertension and right shoulder disability due to service and/or had their onset during service. He testified he hurt his right shoulder in service and now has trouble with basic activities such as taking off a shirt. The question for the Board is whether the Veteran has current disability that manifested in service or within the applicable presumptive period or whether hypertension or right shoulder disability is otherwise related to service. We find that while there is current disability, there was no in-service incurrence or aggravation of a disease or injury nor is there a nexus between current disability and service. Hypertension as demonstrated in the January 2021 VA DBQ. However, the VA examiner found that hypertension first manifested many years following service separation and was not present in service. Hypertension was noted to be shown first in 2014. Consistent with that finding, we note that at his May 1992 service separation examination, blood pressure was recorded but hypertension was not noted at that time or elsewhere in his STRs. He denied high blood pressure at separation. Also, post service treatment records show hypertension from approximately 2013. There is current disability of right shoulder arthritis as demonstrated in VA and non-VA treatment records dating from 2011. We do note that the VA shoulders examiner in 2021 listed no current right shoulder disorder. Here, the treatment record reflects that the right shoulder disorder first manifested many years following service separation and was not present in service. STRS are absent complaints of or treatment for the right shoulder. The May 1992 clinical examination at separation was negative for the upper extremities. The Veteran denied painful or trick shoulder. The Board concludes that, while the Veteran has hypertension and right shoulder arthritis, which constitute chronic disease under 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a), these did not manifest in service or within a presumptive period, and continuity of symptomatology is not established. Rather, they were both first shown years after service. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). To the extent that the Veteran alleges the conditions were present in service, and there has been continuity of symptomatology since service, the record is against his assertions. His assertions are outweighed by the negative treatment record prior to 2011 for the right shoulder and 2013 for hypertension. While the Veteran is competent to report having experienced certain symptoms, his assertions are considered not credible to the extent that he urges he had symptoms since service or during service or within the presumptive period due to (1) the denial of symptoms at separation coupled with (2) the gap in time between service separation in 1992 and the first documentation of signs and symptoms decades later. The Board accords substantial probative weight to the competent medical evidence, the treatment records (and the January 2021 VA medical opinion as to hypertension), which are the most probative evidence that these conditions first manifested years after service, and not during service or during a presumptive period. The Veteran's assertions are outweighed by this evidence. The preponderance of the evidence is also against finding that a nexus exists between the Veteran's hypertension or right shoulder disorder and service. 38 U.S.C. § 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Here, the Board notes that these conditions have not been related to service by any competent evidence. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. None of the treatment records contains an opinion that hypertension or right shoulder disability is related to service. The opinion of the January 2021 VA examiner is that hypertension is less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner provided a rationale that was sound and fully considered the evidence of record. It noted that STRs did not contain complaints, treatment, or diagnosis for hypertension and that the condition was not shown until 2014, over twenty years after he was released from active duty. The examiner noted no new evidence was presented to prove otherwise. Here, neither hypertension nor arthritis of the shoulder were noted, diagnosed or manifest in service or within one year of separation. Any assertion of continuity is accorded less probative value than the separation examination and his denial of pertinent pathology at that time. While the Veteran believes hypertension and right shoulder disability are related to service, his lay opinion as to a nexus is outweighed by negative treatment record as to both claims and the well-supported opinion of the VA examiner in 2021 as to hypertension. There is no competent/credible evidence that hypertension or a right shoulder disability is related to service. The weight of the evidence is against concluding that any such disease was incurred in service. 38 C.F.R. § 3.303 (d). The preponderance of the evidence weighs against finding that the conditions were occurred in or is otherwise related to service. 5. Entitlement to service connection for a cervical spine disability to include as secondary to service-connected disease or injury is denied. 6. Entitlement to service connection for headaches to include as secondary to service-connected disease or injury is denied. 7. Entitlement to service connection for a right knee disability to include as secondary to service-connected disease or injury is denied. 8. Entitlement to service connection for a left knee disability to include as secondary to service-connected disease or injury is denied. The issue for the Board is whether the Veteran has current disability that began during service or within an applicable presumptive period or is at least as likely as not related to an in-service injury or disease or is proximately due to or aggravated by a service-connected disability. We find that while there is post service disability, there was no in-service incurrence or aggravation of a disease or injury or incurrence within the applicable presumptive period nor is there a nexus between current disability and service nor is current disability proximately due to or aggravated by a service-connected disease or injury. The Veteran seeks service connection for headaches, cervical spine and bilateral knee disabilities; he reports that he has headaches related to his in-service rugby or as secondary to his service-connected tinnitus. He reports that he has cervical spine and left knee problems related to his in-service duties as an air traffic controller or as secondary to his service-connected left ankle disability. He testified that he has pain in both knees related to service. We note that STRs are largely absent complaints of or treatment for these problems with the exception that he was treated for a left knee abrasion in July 1990. Also, there is notation in his July 1988 enlistment physical that he reported a history of fracture of the right knee in 1982. Examination and X-ray at that time resulted in a finding of normal right knee. Also, he had reported a history of concussion but there were no relevant findings. The July 1988 enlistment examination was wholly negative on clinical evaluation as to all body systems. The May 1992 clinical examination at separation was negative for the head, lower extremities and spine and any report or observation of headaches. The Veteran denied current or a history of frequent or severe headaches, trick or locked knee or recurrent back pain. First, we note that we find no pre-existing conditions with regard to the right knee and headaches. The enlistment examination unequivocally shows there were no conditions noted at entrance into service. 38 C.F.R. § 3.304. Next, we note that there is current disability; bilateral knee strain, migraine headaches and cervical spine degenerative arthritis are reflected in the January 2021 VA DBQs. Next, while bilateral knee strain is not a chronic disease under 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a), migraines (other organic diseases of the nervous system) and cervical spine arthritis constitute chronic diseases, but they did not manifest in service or within a presumptive period, and continuity of symptomatology is not established. Rather, they were first shown years after service. 38 U.S.C. §§ 1101(3), 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). To the extent that the Veteran alleges the migraines and cervical spine disability were present in service, and there has been continuity of symptomatology since service, the record does not support his contentions. His assertions are outweighed by the negative treatment and examination record in service and in the initial post service year. We do not find evidence of migraines or cervical spine arthritis until well over a decade after separation. While the Veteran is competent to report having experienced certain symptoms, his assertions that he had neck pain and headaches since service or within the presumptive period are considered not credible due to (1) the denial of symptoms at separation coupled with (2) the gap in time between service separation in 1992 and the first documentation of signs and symptoms of migraines and cervical spine problems years after service. The Board accords substantial probative weight to the competent medical evidence, the treatment record and the January 2021 VA medical opinions, which together are the most probative evidence that cervical spine arthritis and migraines first manifested years after service, and not during service or during a presumptive period. The Veteran's assertions are outweighed by this evidence. The preponderance of the evidence is also against finding that a nexus exists between the Veteran's bilateral knee strains, migraines or cervical spine disorder and service. 38 U.S.C. § 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Here, the Board notes again that these each began years after service, and also that they have not been related to service by any competent evidence. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. None of the treatment records contains an opinion that bilateral knee strains, migraines or cervical spine disorder is related to service. The opinion of the January 2021 VA examiner is that bilateral knee strains, migraines or cervical spine disorder are less likely than not (less than 50% probability) incurred in or caused by a claimed in-service injury, event or illness. The examiner provided a rationale for each disorder that was sound and fully considered the evidence of record. As to the knees, the examiner noted the August 2016 VA examination diagnosis of left knee strain, without mention of right knee strain, as well as the negative separation exam in May 1992. The Veteran reported the conditions began between 1988 and 1989 due to an injury from physical training. The examiner continued as follows: A knee strain occurs when a muscle or tendon is torn or stretched. The tendons are fibrous cords that connect muscles to bones. Simple knee strains or sprains can last for one to two weeks. More extensive injuries requiring arthroscopic surgery may take one to three months to heal. Major traumatic injuries to the knee may take up to a year to heal. Causes of a knee strain or sprain include: Injuries such as trauma, sports injuries or falls that overstretch the joints and soft tissue that surround the knee and cause a knee sprain or strain; Overuse building up too quickly in a sport, such as running, can overwhelm the body and lead to knee strains or sprains; Muscle weakness muscles that can't support the knee joints can cause a knee strain or sprain; Reduced flexibility tight muscles can restrict joint motion and lead to functional weaknesses at the knee joint to cause a knee strain or sprain; Running form overpronating when running or walking can increase stress to the knee and cause a knee strain or sprain. The Veteran left the military service in 1992, almost 28 years ago. It could not be that the condition which started over 2 decades could have caused an acute knee injury. As to cervical spine arthritis, they noted the Veteran reported the condition began in 1990 and 1991 with a motorcycle accident and later playing rugby. The examiner stated: Osteoarthritis is also known as degenerative joint disease. It is a condition in which the protective cartilage that cushions the tops of bones degenerates, or wears down. This causes swelling and pain. It may also cause the development of osteophytes, or bone spurs. Osteoarthritis of the spine is a breakdown of the cartilage of the joints and discs in the neck and lower back. In general, osteoarthritis happens as people get older. Younger people may get it from one of different causes: Injury or trauma to a joint a genetic defect involving cartilage. Biochemically, aging increases the ratio of Keratin sulfate to Chondroitin sulfate, and it also changes the proportion Chondroitin-4-sulfateto Chondroitin-6-sulfate, with a parallel decrease in water content. Whereas sagittal alignment, facet joint arthritis and genetics potentially play a role in intervertebral disk degeneration, the results of one study suggested that the rate of degeneration may be associated with age. Being a traffic controller cannot cause injury to the cervical spine... As to migraines, the Veteran reported to the examiner that they began in the fall of 1988 after witnessing a suicide on the firing line. He reported seeing red, being unable to think straight, and having head pain at the time. The examiner found the that current headaches were less likely than not (less than 50 percent probability) incurred in or caused by headaches during the Veteran's service, to include playing rugby. It was noted that STRs did not contain complaints, treatment, or diagnosis and that no other evidence was presented to prove otherwise. We find the 2021 opinions of the VA examiner, made based upon a thorough review of the claims folder, well-supported with references to the record. They are more probative as to the issue of whether any current disability is related to service than the Veteran's vague assertions made in connection with the claim. His assertions pale in comparison to the opinion of a trained medical professional. The VA examiner considered the Veteran's theory as to a relationship and provided sound reasons for ultimately rejecting it. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wray v. Brown, 7 Vet. App. 488 (1995) (the Board may adopt a particular independent medical expert's opinion for its reasons and bases where the expert has fairly considered the material evidence of record). The 2021 opinions are the most probative evidence as to these issues. We accord them significant probative weight. The preponderance of the evidence is against the claims. As the Veteran claimed these disorders were alternatively proximately due to or aggravated by service-connected disability, the examiner opined on this as well. The opinion as to each disorder was in the negative. As to the cervical spine, the examiner found it less likely than not (less than 50 percent probability) proximately due to or the result of a service-connected condition and or aggravated by service-connected left ankle degenerative joint disease status-post fracture. They noted that STRs are absent complaints of/or treatment for a cervical spine condition and so the baseline cannot be established. They stated that cervical X-ray in February 2017, almost 25 years after military service, showed still mild degenerative joint disease of the cervical spine. They observed that the left ankle degenerative joint disease status-post fracture cannot aggravate a condition that was not even proven to be existent in service. They also explained that the left ankle degenerative joint disease status-post fracture, did not cause degenerative arthritis of cervical spine. As to headaches, the examiner found them less likely than not proximately due to or the result of or aggravated by a service-connected condition to include tinnitus. They cited medical literature and observed that tinnitus, the perception of sound in the absence of a corresponding sound source, is a frequent disorder. In some forms of tinnitus, there is an internal sound source like sounds from abnormal blood flow because of vascular anomalies or palatal myoclonus. In the previous studies, an association between tinnitus and headaches has been demonstrated. These studies indicate that between 26 and 47% of patients with tinnitus also suffer from headache. Tinnitus does not cause headache. Headache is usually comorbid with tinnitus" and according to American Migraine Foundation Tinnitus can be associated with multiple types of headache disorders. One headache type where tinnitus is sometimes seen is migraine. Some patients report that their tinnitus worsens only and consistently during migraine attacks. Multiple hypotheses have been formed to explain why tinnitus and headache may co-occur. Some researchers suggest that it could be from spontaneous abnormal neural activity. Others suggest it may be an allodynic symptom. More investigation needs to be done in this area. There is no study however that tinnitus aggravates headache. As to the knees, the examiner found the current condition less likely than not caused or aggravated by service-connected left ankle degenerative joint disease status-post fracture. They noted that he left military service in 1992, almost 28 years ago and that it could not be that the condition which started over 2 decades could have caused an acute knee injury. The Veteran's lay opinion as to secondary service connection is outweighed by the above well-supported opinions of the VA examiner in 2021. The medical opinions are indeed consistent with the documented record. Because the medical opinions are well-supported, and based on a comprehensive review of the record by a medical professional, the Board gives them more probative weight than the Veteran's wholly unsupported lay assertions. There is no competent evidence that bilateral knee strain, cervical spine disability or migraines are proximately due to or aggravated by service-connected disability. The weight of the evidence is against so concluding. The appeals are denied. Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings." Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. On remand, current VA examinations were obtained as it was noted that the Veteran testified that his conditions were worse than indicated in the August 2016 VA examinations. He stated that he was able to lift his left arm above his shoulder level, but that was painful. He further testified that he was not able to scratch his back or cut his hair. Additionally, it was noted that chiropractic treatment records suggested the possibility that the left ankle disability was worse than rated. 9. Entitlement to a 10 percent disability rating for left ankle degenerative joint disease status-post fracture prior to August 12, 2016 is granted; a rating in excess of 10 percent is denied at all times. The Veteran seeks a higher rating for the left ankle disability, rated noncompensable prior to August 12, 2016 and then 10 percent disabling under DCs 5003-5271 for traumatic arthritis (5010) of the ankle with limited motion of the ankle (5271) under the Schedule of Ratings musculoskeletal system with consideration of painful motion. 38 C.F.R. §§ 4.71a, 4.59. As of August 12, 2016, the 10 percent rating is based on moderate limitation of motion of the ankle, with the notation that it was based on dorsiflexion less than 15 degrees. The question for the Board is whether he meets or approximates the criteria for a higher rating for the left ankle at any time within the appeal period. The Board finds that while a 10 percent rating is supported based on functionally moderate limitation of ankle motion for the period on appeal prior to August 12, 2016, the preponderance of the evidence is against finding a rating in excess of 10 percent at any time, for the following reasons. First, we find that the January 2021 ankle DBQ is the most accurate assessment of the current manifestations of the left ankle. It is comprehensive and based upon a review of the entirety of the record as well as examination, to include the treatment records obtained on remand. It is considered wholly consistent with the treatment record as to degree of disability throughout the rating period. It is fully compliant with 38 C.F.R. §§ 4.40, 4.45, 4.59, and the related case of Correia v. McDonald, 28 Vet. App. 158 (2016), with regard to joint testing and the assessment of functional loss during flare-ups. Higher ratings include, under DC 5271, a 20 percent evaluation for marked limitation of motion of the ankle. Under DC 5270, ankylosis of the ankle in plantar flexion, less than 30 degrees, also warrants a 20 percent rating. A 30 percent evaluation is warranted for ankylosis in plantar flexion, between 30 and 40, or in dorsiflexion, between 0 and 10 degrees. 38 C.F.R. § 4.71a. VA left ankle examination in January 2021 reflects that the diagnosis is left ankle degenerative joint disease status post fracture. He reported the injury was due to a motorcycle accident in 1991. He reports no mobility, no flexibility and constant pain. Flare-ups of the right ankle occur daily. The right ankle flare-ups are moderate to severe. The right ankle flare-ups last 30 minutes to 3 days. The right ankle flare-ups are precipitated by walking, standing, sleeping, and running. The right ankle flare-ups are alleviated by elevation and ice. Functional loss was reported by the Veteran as no flexion, no mobility, severe limp, limited walking and standing. He noted he cannot exercise, can perform no prolonged standing or running, and is off balance. The examination was noted to actually be conducted during a flare-up. There is no ankylosis of the ankle, subtalar or tarsal joint. Range of motion of the left ankle was dorsiflexion 0 to 15 out of 20 degrees and plantar flexion 0 to 35 out of 45 degrees. Pain was noted with plantar and dorsiflexion to cause functional loss but there was no additional functional loss after three repetitions. There was evidence of pain on weight-bearing with objective evidence of moderate localized tenderness. There was no crepitus. Pain did significantly limit functional ability with repeated use over a period of time and during flare-ups. But the most restrictive range of motion was as listed above since a flare-up was occurring. Swelling, disturbance of locomotion and interference with standing were contributing factors. Muscle strength was normal and there was no atrophy. Ankle instability or dislocation was not suspected. The Veteran had not had "shin splints", stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or a talectomy (astragalectomy). Functional impact from the left ankle on the ability to perform occupational tasks was he could not stand more than 10 minutes without pain. There were no other pertinent physical findings, complications, conditions, signs or symptoms. There was evidence of pain on passive range of motion of the left ankle but no pain on non-weight bearing in the left ankle. The treatment records dated during the appeal period include chiropractic records that note consistent pain in the left ankle. We note that the earlier ankle examination in August 2016 reflects plantar flexion to 45 degrees and dorsiflexion to 10 degrees. The Board finds that the January 2021 VA ankle examination report and treatment records, along with the hearing testimony, show that the Veteran's left ankle disability fits squarely within the criteria for a 10 percent rating under DC 5271 at all times relevant to the claim. The Veteran's description of pain flare-up and limited motion throughout the appeal period, to include as explained at the hearing, is sufficient to assess the condition as functionally moderate limitation of ankle range of motion for the period on appeal prior to August 12, 2016. However, the preponderance of the evidence is against finding there is marked limitation of motion or a higher degree of impairment, such as ankylosis, at any time. The 2021 VA examiner specifically found no ankylosis. Nor is there any suggestion in the record of the functional equivalent of ankylosis as discussed in Chavis v. McDonough, No. 18-2928, slip op. (U.S. Vet. App. Apr. 16, 2021). He retains functional movement as demonstrated on the examinations. He uses no assistive devices. His assertion of no motion is inconsistent with record ans is not credible. The Board finds the 2021 VA examiner's assessment to be highly probative as to the degree of disability. It is consistent with the treatment record and was made based in part on the Veteran's descriptions of symptoms and his current flare-up. A 10 percent rating and no higher adequately represents functional impairment attributable to the disability. See 38 C.F.R. §§ 4.41, 4.10. To the extent that the Veteran urges that the criteria for a higher rating are met or approximated other than what was awarded herein, his assertions are outweighed by the treatment and examination record which are against this assertion, as discussed above. His complaints at the 2021 examination are noted to have been recorded during a flare-up and represent the highest degree of impairment during the appeal period. The criteria for a higher rating are not met or approximated at any time throughout the appeal period when all the evidence is considered. See 38 C.F.R. § 4.7. There is no reasonable doubt regarding the degree of disability. See 38 C.F.R. § 4.3. Parenthetically, we note that there have been changes to the Schedule of Ratings for the Musculoskeletal System effective February 7, 2021, but these changes do not result in any higher rating for the left ankle disability. Rather, the changes, in relevant part, clarify that limitation of motion of the ankle under DC 5271 is considered moderate when there is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, and marked when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. The manifestations present and discussed in the Veteran's case do not support higher or additional ratings under any criteria. At a minimum, we accept that there is pain on motion and such supports a 10 percent evaluation. The most probative evidence establishes that there is pain on motion and some limited motion. Such evidence supports a 10 percent evaluation and no ore. 10. Entitlement to a disability rating more than 20 percent for internal derangement with degenerative changes of the left shoulder status-post dislocation is denied The left (minor) shoulder disability is rated 20 percent disabling under DCs 5003 and 5201 using the Schedule of Ratings Musculoskeletal System. 38 C.F.R. § 4.71a. This is representative of degenerative arthritis of the joint established by X-ray in combination with limitation of motion of the arm. Limited motion of the arm at shoulder level was noted. The medical record reflects that the Veteran is right-handed, so this is the non-dominant or minor upper extremity. Again, we find that the January 2021 shoulder DBQ is the most accurate assessment of the current manifestations of the left shoulder. It is comprehensive and based upon a review of the entirety of the record as well as examination. It is considered wholly consistent with the treatment record as to degree of disability throughout the rating period. It is fully compliant with 38 C.F.R. §§ 4.40, 4.45, 4.59, and the related case of Correia v. McDonald, 28 Vet. App. 158 (2016), with regard to joint testing and the assessment of functional loss during flare-ups. Higher ratings under DC 5201 include a 30 percent rating for the minor arm with limitation to 25 degrees from side. The Veteran's arthritis, 38 C.F.R. § 4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint, and the current 20 percent rating takes into account his painful motion. The preponderance of the evidence is against this claim. First, the Board observes there is no ankylosis of the scapulohumeral articulation, nor is there flail joint, false flail joint or fibrous union of the humerus. Nor is there malunion of the humerus with moderate or marked deformity nor is there recurrent dislocation. See December 2016 and November 2019 VA shoulder examinations. Consequently, higher ratings are not warranted based on DCs 5200 (ankylosis) or 5202 (other impairment of humerus). Further, the examination and treatment record does not demonstrate, nor does the Veteran assert that there is limited motion of the arm either midway between side and shoulder level or to the more severe degree, 25 degrees from side. Here, we note he has complained of problems with overhead-type activity. VA examination in August 2016 revealed flexion limited to 90 out of 180 degrees as well as abduction is limited to 90 degrees out of 180 degrees. Pain noted on exam was determined to cause functional loss and was moderate. The functional impact he was limited in reaching, pushing, pulling, carrying, and lifting moderate objects from mid-chest and above but he could perform light physical and sedentary activities. VA examination in January 2021 reflects diagnosis of internal derangement with degenerative changes, left shoulder, status-post dislocation. Flare-ups of the left shoulder occur daily. The left shoulder flare-ups are moderate to severe, last 30 minutes to 6 hours, are precipitated by sleeping, lifting, driving, and working. They are alleviated by nothing. Functional limitations were that he needs help washing, changing clothes, and wiping. He cannot scratch his back or put on a jacket alone. Left shoulder flexion was limited to 160 out of 180 degrees as well as abduction was limited to 160 degrees out of 180 degrees. He cannot raise the shoulder without pain. The examination was conducted during a flare-up. Repetitive use and repeated use over time were not thought to produce additional functional loss. Pain, weakness, fatigability or incoordination did significantly limit functional ability with flare-up, as demonstrated during the examination. Muscle strength was normal and there was no atrophy. There was no evidence of pain on passive range of motion testing of the left shoulder or on non-weight bearing testing. Treatment records do not show a more restricted range of motion of the left shoulder than was demonstrated on the examinations nor are other symptoms noted. Based on the above, the Board finds that the Veteran does not meet or approximate the criteria for a higher rating for the left shoulder. The Board finds the VA examiners' assessments as to range of motion and functional impact to be significant and highly probative as to the fact that motion is not limited to 25 degrees from side, the criteria for a 30 percent rating. The Veteran has not actually made assertions as to limitations in excess of this. Also, the examination in 2021 was conducted during a flare-up, so no further reduction in range of motion due is suggested. He has indicated that he has trouble with overhead work due to problems with his shoulder. The functional limitation identified by both VA examiners is he cannot raise left arm above head without pain. Nor is there any suggestion in the record of the functional equivalent of ankylosis as discussed in Chavis v. McDonough, No. 18-2928, slip op. (U.S. Vet. App. Apr. 16, 2021). He continues to retain motion in the shoulder. The Board finds the observations in the VA reports to be consistent, compelling and uncontroverted evidence that the left shoulder is not productive of any of manifestations warranting a higher rating. Finally, while the Board has considered the actual degree of functional impairment imposed by pain, incoordination, weakness, fatigue, and lack of endurance with repetitive motion, in accordance with 38 C.F.R. § § 4.40, 4.45, 4.59, the totality of the evidence persuades the Board that no factors are present to any appreciable degree that would support or approximate a higher rating. The criteria for a higher rating are not met or approximated at any time throughout the appeal period when all the evidence is considered. See 38 C.F.R. § 4.7. There is no reasonable doubt regarding the degree of disability. See 38 C.F.R. § 4.3 Parenthetically, we note again that there have been changes to the Schedule of Ratings for the Musculoskeletal System effective February 7, 2021, but these changes do not result in any higher rating for the left shoulder disability. Rather, the changes, in relevant part, clarify that limitation of motion of the arm under DC 5201 warrants a 30 percent rating for the minor arm with flexion and/or abduction limited to 25° from side. The manifestations present and discussed in the Veteran's case do not support higher or additional ratings under any criteria. H. N. SCHWARTZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. RIPPEL, 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.