Citation Nr: 21040453 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 15-34 673 DATE: July 3, 2021 ORDER An increased 30 percent rating for left calf laceration residuals with posterior tibial nerve impairment affecting propulsion of the foot is granted. Service connection for a hepatitis C disability is denied. Service connection for vasculitis, including as secondary to service-connected left leg laceration residuals, is denied. A total disability rating based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. Since October 19, 2011, the Veteran's left calf laceration residuals with posterior tibial nerve impairment manifested with symptoms approximating "severe" incomplete paralysis of the posterior tibial nerve. 2. The competent medical evidence indicates the Veteran does not have a current hepatitis C disability. 3. The competent medical evidence indicates the Veteran's vasculitis was not caused or aggravated by his service-connected left calf laceration residuals and is not otherwise related to an injury, disease, or event during active service. 4. Resolving any doubt in the Veteran's favor, his service-connected disabilities prevent him from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for a 30 percent rating for left calf laceration residuals with posterior tibial nerve impairment have been approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.40, 4.45, 4.55, 4.56, 4.59, 4.124a; Diagnostic Code (DC) 8524. 2. The criteria for service connection for hepatitis C have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304. 3. The criteria for service connection for vasculitis have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 4. The criteria for a TDIU due to service-connected disorders have been approximated. 38 U.S.C. § 1155; 38 C.F.R. § 4.16 (a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 1977 to October 1979. VA received his increased rating claim on October 19, 2011. He contends his left calf injury residuals warrant a rating greater than the current 20 percent evaluation, and that his vasculitis and hepatitis C conditions were caused or aggravated by the in-service left calf injury and associated surgeries. The service connection claims are denied because the medical evidence does not show a hepatitis C disability during the appellate period, or a link between vasculitis and the in-service leg injury/surgeries. As explained below, the Board will grant the increased rating claim and assign a TDIU. In September 2018, the Board of Veterans' Appeals (Board) remanded the claims to the VA Regional Office (RO) to schedule additional VA examinations and obtain medical opinions addressing the severity of the Veteran's left calf injury residuals and whether vasculitis and hepatitis C are related to his active service. The examinations and opinions were completed in March and September 2020, and review of the examination reports indicates that the RO substantially complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). The September 2018 decision also remanded the issues of an earlier effective date and increased rating for service-connected scars associated with the left calf laceration (under DC 7801) and directed the RO to issue a statement of the case (SOC). In a June 2019 rating decision, the RO granted an earlier effective date but denied an increased rating. The RO issued a SOC continuing the denial in June 2020, and therefore complied with the Board's remand directives. See Stegall, above. The Veteran did not file a substantive appeal to the June 2020 SOC. Later in June 2020, he filed a supplemental claim seeking earlier effective dates and increased ratings for his scars, cellulitis, and psychiatric conditions. At this time, the Board no longer has jurisdiction over the issues of earlier effective dates/increased ratings for scars (remanded in the September 2018 Board decision). Those issues will be adjudicated separately along with the other issues in the Veteran's June 2020 supplemental claim. 1. Entitlement to an initial rating greater than 20 percent for left calf laceration residuals with posterior tibial nerve impairment affecting propulsion of the foot since October 19, 2011 VA assigns disability ratings by applying criteria in its Schedule for Rating Disabilities (the "Rating Schedule"). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes (DCs). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question of which of two evaluations should be applied, VA will assign the higher evaluation if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Evaluating the same disability under several diagnostic codes, known as pyramiding, must be avoided. VA may assign separate ratings for distinct disabilities resulting from the same injury so long as the symptoms of one condition are not duplicative of or overlapping with the symptoms of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). When a veteran has separate and distinct manifestations caused by the same injury, he should be compensated under different diagnostic codes with different ratings. See Esteban; Fanning v. Brown, 4 Vet. App. 225 (1993). The essential question is whether any of the disabling symptoms are duplicative or overlapping. The Veteran is entitled to a combined rating only where symptoms are distinct and separate. Id. In assigning a higher disability rating, VA is responsible for determining whether the evidence supports the claim or is relatively balanced, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's service-connected left calf laceration residuals have been evaluated as 20 percent disabling for the entire appellate period. The current 20 percent rating is based on the criteria for a "moderately severe" muscle disability under the Schedule of Ratings for Muscle Injuries. See 38 C.F.R. §§ 4.55, 4.56, 4.73; DC 5311. Separate ratings are in effect for painful scars and cellulitis of the left calf, and these ratings are not on appeal. In September 2020, the RO recharacterized the Veteran's left leg condition as "left calf laceration residuals with posterior tibial nerve impairment affecting propulsion of the foot," but continued the 20 percent rating based on moderately severe muscle injury. Given the Veteran's posterior tibial nerve damage, the Board will also consider the criteria for peripheral nerve disorders. See 38 C.F.R. § 4.124a. For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in five anatomical regions. The "foot and the leg" is one anatomical region divided into three muscle groups (DCs 5310 through 5312). See 38 C.F.R. § 4.55. The Veteran's left calf laceration residuals are currently evaluated under DC 5311, which assigns ratings for Muscle Group XI. Muscle Group XI includes the posterior and lateral crural muscles and muscles of the calf: (1) Triceps surae (gastrocnemius and soleus); (2) tibialis posterior; (3) peroneus longus; (4) peroneus brevis; (5) flexor hallucis longus; (6) flexor digitorum longus; (7) popliteus; (8) plantaris. These muscles affect propulsion, plantar flexion of the foot, stabilization of the arch of the foot, and flexion of the knee. DC 5311 assigns ratings for Muscle Group XI and provides a 10 percent rating for a moderate muscle injury, a 20 percent rating for a moderately severe muscle injury, and a 30 percent rating for a severe muscle injury. See 38 C.F.R. § 4.73, DC 5311. The criteria for a "moderately severe" muscle disability are: (i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. The criteria for a "severe" muscle disability are: (i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. See 38 C.F.R. § 4.56. For VA rating purposes, the "cardinal signs and symptoms" of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56. A muscle injury rating will not be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. 38 C.F.R. § 4.55 (a). DC 8524 assigns ratings for paralysis of the tibial nerve, and provides a 10 percent rating for mild incomplete paralysis; a 20 percent rating for moderate incomplete paralysis; and a 30 percent rating for severe incomplete paralysis. A 40 percent rating is assigned for complete paralysis with plantar flexion lost, frank adduction of foot impossible, flexion and separation of toes abolished; no muscle in sole can move; in lesions of the nerve high in popliteal fossa, and plantar flexion of foot lost. See 38 C.F.R. § 4.124a, DC 8524. The term "incomplete paralysis" means a degree of lost or impaired function less than the type picture for complete paralysis given with each nerve. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The terms "slight," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence and issue a decision that is "equitable and just." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59. Provision 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion (ROM) measurements. Under 38 C.F.R. § 4.45, functional loss due to weakened movement, excess fatigability, and incoordination must also be considered. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995) (holding that the criteria discussed in sections 4.40 and 4.45 are not subsumed by the DCs applicable to the affected joint). Although the factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on limited motion under 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("The guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). The provisions of 38 C.F.R. § 4.59 recognize that painful motion is an important factor of disability. Joints that are painful, unstable, misaligned or due to healed injury are entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive ROM of both the damaged joint and the opposite undamaged joint. Id.; see Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that § 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) (holding that pain alone does not constitute function loss and is just one fact to be considered when evaluating functional impairment). In February 2012, the Veteran was afforded VA examinations addressing scars, vascular conditions, and skin diseases affecting his legs. Although these examinations did not specifically focus on the Veteran's left leg muscle injury and nerve damage, the examiners noted the Veteran regularly used a cane for left leg pain and foot weakness. During the February 2012 VA scar examination, the examiner noted physical findings in addition to painful scars, including decreased sensation in the sole of the left foot, numbness, and weakness due to nerve injury. The examiner noted these neurological symptoms impaired the Veteran's ability to walk and balance and resulted in an abnormal gait. In a November 2015 VA record, the Veteran reported pain in his left leg of "4/10." He reported he had left leg pain for 40 years and it improved with medication. An August 2016 VA record noted the Veteran had "good strength and tone" of his bilateral lower extremities and a neurological examination was negative for any abnormalities. A December 2016 VA record noted that, on physical examination, the Veteran had weakened left ankle plantar flexion and decreased sensation in the bottom left foot. He had normal reflexes in his lower extremities and his gait was within normal limits at that time. The Veteran continued to report left leg pain in January 2017 and August 2018. The Veteran also reported pain, swelling, and difficulty walking due to vasculitis. VA medical providers noted the Veteran had left leg neuropathy in addition to vasculitis. In June 2019, the Veteran reported episodes of increased left leg pain at a "4/10" in severity. On physical examination, the attending clinician noted normal muscle strength and found no evidence of tenderness or loss of motion of the joints. The clinician noted the Veteran's gait was steady. In a February 2020 VA primary care record, the Veteran reported his chronic left leg pain had worsened. On physical examination, the attending clinician noted scarring on the left leg with minimal atrophy and limited dorsi/plantar flexion. The clinician also noted the Veteran was leaning on his right leg. During a March 2020 VA muscle injuries examination, the Veteran reported numbness in the back of his left leg and bottom of his foot. He reported these symptoms began in 1978 and had not changed since that time. He reported regularly using a cane. The VA examiner noted the Veteran's left calf laceration residuals involved Muscle Group XI (posterior and lateral crural muscles and muscles of the calf) but no other muscle group. The examiner noted the Veteran's muscle injury did not affect muscle substance or function, but caused weakness, fatigue and pain. Physical examination revealed normal muscle strength in the lower extremities and the examiner noted the Veteran did not have muscle atrophy. She noted minimal scarring on the left leg but no other abnormalities. The examiner opined the Veteran's left calf laceration residuals made him unable to perform work tasks involving ambulation or physical labor, and the Veteran would have reduced productivity in any occupation requiring frequent movement. The examiner opined the Veteran's left calf laceration residuals caused "mild to moderate" weakness, fatigue and pain and characterized the condition as "mild to moderate." She concluded the diagnosis had not changed. In a May 2020 statement, the Veteran's daughter reported that the Veteran walked with a limp and "shuffled" often due to his left leg. She reported that the Veteran's left leg often swelled, changed colors and sometimes looked purple. She reported the Veteran could not perform heavy lifting and had difficulty staying active because of his left leg. During a September 2020 VA peripheral nerves examination, the Veteran reported he had no feeling in the bottom of his left foot, limited movement, sore ulcers, numbness in the back of his leg, chronic nerve pain, and loss of use. He continued to report regularly using a cane for support and balance. The examiner noted moderate numbness in the left leg. Physical examination revealed reduced ankle plantar flexion, reduced deep tendon reflexes of the ankle, and decreased sensation to light touch in the left lower leg, ankle, foot and toes. The examiner noted the Veteran had an abnormal gait due to nerve damage of the left leg. She noted scars on the left leg that were not painful or unstable. The examiner noted the Veteran had visible atrophy of his left calf when compared to the right. The diameter of the left calf measured 1 cm less than the right. The examiner also noted the visible atrophy of the left calf was greater than was measured during physical examination. The September 2020 examiner opined the Veteran's functional loss included inability to perform full ROM of the toes, reduced strength of the left great toe, reduced plantar flexion of the toes of the left foot, numbness of the sole of the left foot and web-spaces, and weak inversion and plantar flexion of the left foot. She opined that the Veteran had "mild" incomplete paralysis of the tibial nerve, and his current symptoms were due to tibial nerve damage. From October 19, 2011 to September 2, 2020, the Veteran's left calf laceration residuals with posterior tibial nerve impairment manifested with pain, weakness, fatigue, numbness, diminished and weakened plantar flexion of the left foot, decreased sensation, functional impairment of difficulty with walking, balance, and heavy lifting, and an abnormal gait requiring regular use of a cane. Since the September 2, 2020 VA examination, the Veteran's left leg condition manifested with additional symptoms of visible and measurable muscle atrophy of the left calf, and decreased deep tendon reflexes. The Board will resolve any doubt in the Veteran's favor and grant a 30 percent increased rating based on symptoms approximating "severe" incomplete paralysis of the posterior tibial nerve. See 38 C.F.R. § 4.124a, DC 8524. Throughout the period on appeal, the Veteran has had decreased sensation, pain, fatigue, weakness, and reduced muscle strength due to nerve damage. He has consistently had an abnormal gait and used a cane for balance. While the September 2020 VA examiner opined the Veteran's incomplete paralysis was "mild," the examiner also noted visible muscle atrophy, reduced muscle strength, reflexes, and sensation. As noted above, the Board is not bound by the examiner's assessment of a "mild" incomplete paralysis and must consider all the evidence in reaching a decision. Resolving any doubt in his favor, the medical evidence indicates the Veteran's tibial nerve impairment is not wholly sensory and manifested with symptoms approximating "severe" incomplete paralysis during the entire appellate period. See DC 8524. The effective date of the 30 percent rating is October 19, 2011, the date the Veteran's increased rating claim was received. Effective October 19, 2011, the 30 percent rating under DC 8524 replaces the existing 20 percent rating under DC 5311. The Board may use alternative diagnostic codes to more accurately reflect a veteran's symptoms. See Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011) (holding that service connection for a disability is not severed when the situs of the disability, or the diagnostic code associated with it, is corrected to more accurately determine the benefit to which a veteran may be entitled for a service-connected disability). Here, the medical evidence indicates that the Veteran's left leg symptoms are most accurately classified as a posterior tibial nerve impairment under DC 8524. A 30 percent rating is the highest rating available under both DC 8524 (nerve impairment) and 5311 (muscle injury). The preponderance of the evidence is against assigning separate ratings for muscle injury (DC 5311) and nerve damage (DC 8524). The September 2020 VA examiner noted the Veteran had tibial nerve impairment, and the Veteran's left calf muscle injury affects the posterior tibia muscle, which is located in same part of the body as the tibial nerve. As noted above, VA regulations provide that muscle injury ratings will not be combined with peripheral nerve paralysis ratings of the same body part, unless the injuries affect entirely different functions. 38 C.F.R. § 4.55 (a). The September 2020 examiner explained that the symptoms previously attributed to a tibial muscle injury have likely been caused by tibial nerve damage. As the Veteran's muscle injury and nerve damage affect the same part of the leg, manifest with the same symptoms, and do not affect "entirely different functions," separate ratings are not warranted. For the reasons above, the Board will assign a 30 percent increased rating for the Veteran's left calf laceration residuals with posterior tibial nerve impairment, based on "severe" incomplete paralysis of the posterior tibial nerve. Effective October 19, 2011, the previous 20 percent rating (under DC 5311) is increased to 30 percent and reclassified under DC 8524. Service Connection VA awards service connection for disabilities resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). "Direct" service connection requires: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus (a causal link) between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge may still be service-connected if the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303 (d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). A veteran may establish service connection on a "secondary" basis for a non- service-connected disability that was caused by a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In deciding an 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 explain its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination about the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran's disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104 (a). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is approximately balanced, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Hepatitis C To support a finding that the Veteran contracted hepatitis C in service, it must be shown that he or she was exposed to one of the medically recognized risk factors for contracting hepatitis C during that time. Risk factors include intravenous (IV) drug use, blood transfusions before 1992, hemodialysis, intranasal cocaine use, high-risk sexual activity, accidental exposure while a health care worker, and various kinds of percutaneous exposure such as tattoos, body piercing, acupuncture with non-sterile needles, and shared toothbrushes or razor blades. The Veteran contends he contracted hepatitis C during a blood transfusion (or transfusions) during in-service surgeries to repair a severed tibial artery, vein, and nerve. This is the only risk factor for hepatitis C the Veteran has identified, and he denies all other risk factors. Service treatment records (STRs) do not contain diagnosis, treatment, or reports of hepatitis C or related symptoms. STRs indicate that the Veteran underwent surgeries for a severe left calf laceration in July 1978 and August 1978. Hospital records describe the surgical procedures in detail but do not reference a blood transfusion. There are otherwise no references to blood transfusions or attempted blood transfusions in the STRs. An August 1978 hospital discharge summary indicated the Veteran underwent a vein interposition graft of the posterior and anterior tibial arteries, debridement of posterior compartment musculature, and reapproximation of the posterior calf muscles with placement of Hemovac wound drains. The report noted the Veteran's wounds were healing well and did not reference a blood transfusion. A June 1979 document titled "Report of Medical Board" noted the Veteran's surgical incisions completely healed and there was no problem or disability at that time. The report indicated that lab studies were not considered necessary. The Veteran had residual weakness and decreased sensitivity in his left calf and foot. In a February 2012 statement, the Veteran reported that he received unscreened blood transfusions in connection with his left leg surgeries. He asserted that the blood transfusions should be documented in his medical records. He reported he was treated for hepatitis C from 2003 to 2004 and denied ever using drugs other than alcohol and tobacco. In a May 2013 statement, the Veteran denied accidental exposure to blood by health care workers, intravenous drug use or intranasal cocaine use, engaging in high risk sexual activity, other percutaneous exposure to blood. He reported the only organ transplant he had was surgery for a nerve taken from his right ankle and implanted in his left calf, and the only blood transfusions he ever received were for his service-connected left calf laceration and operations. The Veteran asserted that the blood transfusions should be documented in hospital records from the three hospitals where he was treated for the left calf injury in 1978. As stated above, these hospital records do not reference any blood transfusions. The Veteran is competent to report that he received a blood transfusion during service. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a lay person is competent to report on that of which he or she has personal knowledge). However, his assertions are outweighed by the medical evidence. Records of the 1978 surgeries described the procedures in such detail that it is implausible that a blood transfusion would not have been recorded. The Board finds that if the Veteran had a blood transfusion, this would have been normally recorded and that the absence of this information weighs heavily against the claim. See AZ v. Shinseki, 731 F.3d 1303, 1315-16 (Fed. Cir. 2013) (silence within records is pertinent evidence when records would typically document event in dispute); see also Horn v. Shinseki, 25 Vet. App. 231, 239 (2012) (The Board may draw inferences against the claimant from the absence of documentation when there is logical reason to suppose that the event or condition would have been recorded). The preponderance of the evidence is against finding that the Veteran underwent a blood transfusion in connection with his 1978 surgeries. Private medical records reflect that the Veteran was tested for Hepatitis C antibodies as early as December 2002. A December 2002 blood test indicated a Hepatitis C antibody test was conducted "for research use only," "and should not be used as the sole criteria for the diagnosis of HCV." In a December 2002 private medical record, the Veteran reported he was diagnosed with hepatitis C in April 2002 after being injured in a motorcycle accident. He reported he had a blood transfusion in 1978 but denied any other risk factors for hepatitis C. The attending physician noted the Veteran's hepatitis was asymptomatic. The physician noted that blood testing revealed hepatitis C antibodies and ordered additional tests to confirm the presence of the virus itself. A February 2003 clinical record noted the Veteran had asymptomatic hepatitis C, genotype I, with a high viral load. Additional private medical records reflect that the Veteran underwent a 48-week treatment for hepatitis C from March 2003 to February 2004. A May 2003 record noted the Veteran achieved virologic response to treatment and blood test of the same date revealed a viral load of less than 600 IU/mL. A February 2006 clinic note indicated that blood tests in February 2005 and February 2006 were also negative for the hepatitis C virus. The clinician explained that Veteran would always test positive for the hepatitis C antibody, but the Veteran was no longer considered infectious. Medical records and diagnostic tests from 2011 to 2016 continued to reflect the presence of Hepatitis C antibodies, but not the virus itself. In a January 2016 record, the attending clinician noted the Veteran did not have a detectable viral load. She noted the presence of antibodies indicated the Veteran was exposed to the virus, but he was either treated or the virus cleared spontaneously. The clinician noted this occurs in 15 percent of people exposed to the virus. During a March 2020 VA examination, the Veteran reported he did not remember when he had hepatitis C, although he speculated that he developed the disease in the 1990s. He continued to report that he received a blood transfusion in 1977 in connection with a nerve transplant surgery. He reported symptoms of fatigue and that his condition progressed since its onset. Blood tests performed at the examination were positive for Hepatitic C antibodies but negative for the virus. The VA examiner explained that some people have antibodies associated with the virus that can lead to a false positive test for an active infection or indicate past treatment. The examiner opined there was no evidence of the hepatitis C virus at the time of the examination. She noted that she reviewed the Veteran's service medical records, including hospital records related to the 1978 surgeries, but found no evidence of a blood transfusion. The examiner also reviewed post-service medical records noting the Veteran did not have a detectable viral load. Based on this evidence and diagnostic testing during the examination, the examiner concluded the Veteran did not meet the criteria for persistent hepatitis C and therefore the condition was not likely related to service. The preponderance of the evidence is against finding that the Veteran has a current hepatitis C disability. The Veteran reported being diagnosed with asymptomatic hepatitis C in April 2002, and blood tests since that time indicate that the virus has not been detectable since May 2003. After reviewing the Veteran's medical history and performing additional diagnostic tests, the March 2020 VA examiner confirmed that the Veteran did not meet the criteria for persistent hepatitis C. The examiner explained that the presence of hepatitis C antibodies in the Veteran's blood did not indicate an active infection. Without proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Service connection may only be awarded to an applicant who has a disability existing on the date of application or at any time during the appellate period, not for past disability. Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997)); Romanowsky v. Shinseki, 26 Vet. App. at 294. The competent medical evidence indicates the Veteran's hepatitis C resolved before the appellate period. Therefore, the preponderance of the evidence is against finding a current disability and the claim is denied. The Board has considered the Veteran's lay assertions that he contracted hepatitis C from blood transfusions he received in service. However, as a layperson, he lacks the medical training to diagnose a complex medical condition (such as hepatitis) or give an opinion as to its cause. See Woehlaert v. Nicholson, 21 Vet App. 456 (2007). The Board has considered remanding the claim for another VA examination to obtain an opinion evaluating the risk factors for hepatitis C and the likelihood of the Veteran's exposure to the virus during the 1978 surgeries. However, the medical evidence establishes that the Veteran does not have a current hepatitis C disability and the virus has not been detected in his blood since 2003, well before the period on appeal. Further examination is not needed to decide the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); see Gilbert, above. 3. Vasculitis, including as secondary to service-connected residuals of a left leg laceration The Veteran was diagnosed with leukocytoclastic vasculitis (LCV) in 2011. He contends his current vasculitis condition was caused by his 1978 left calf surgeries. Alternatively, he contends his vasculitis was aggravated by his service-connected residuals of the left calf injury. The Veteran is service-connected for cellulitis, which also manifests with a skin rash but is a separate medical condition. The Veteran does not contendand the evidence does not showthat vasculitis manifested in service. STRs are silent for diagnoses or treatment for vasculitis. Records of the 1978 surgeries noted residual numbness, weakness, and difficulty walking but not vasculitis or any external skin or vascular symptoms. Private medical records reflect that the Veteran developed a rash in May 2011 that spread from his ankles to his head, hands, upper arms, forearms, and legs. He reported being bitten by a tick and his medical providers initially suspected he contracted Rocky Mountain Spotted Fever (RMSF) from the tick bite. The Veteran was prescribed antibiotics for RMSF but his rash worsened. Later in May 2011, the Veteran's medical providers opined that the rash was not RMSF and was possibly caused by "reactivated" hepatitis C or cryoglobulinemia, a type/variation of vasculitis. The Veteran was hospitalized in June 2011 when his rash continued to worsen. Hospital records noted the Veteran's hepatitis C appeared to have cleared at that time. Later in June 2011, the Veteran's dermatologist performed a punch biopsy and concluded the Veteran's rash was consistent with LCV. The Veteran's medical providers offered different opinions as to what caused the Veteran's vasculitis. The list of possible causes included a drug reaction, cryoglobulin, or vasculitis secondary to hepatitis C. Two of the Veteran's dermatologists opined that a drug reaction was the most likely cause. They indicated that vasculitis may have been a reaction to antibiotics the Veteran took for RMSF. An August 2011 dermatology record noted the Veteran did not have active vasculitis or systemic symptoms at that time. The attending clinician noted the Veteran's vasculitis reoccurred when the Veteran took a reduced dose of prednisone (a steroid). In September 2011, the Veteran reported numerous flares of skin vasculitis brought on by stress. He reported that prednisone alleviated these symptoms. In October 2011, the Veteran reported he had no vasculitis "whatsoever." An October 2011 dermatology record noted the Veteran had been treated at multiple hospitals and evaluated by medical providers specializing in Allergy, Immunology, and Rheumatology. One dermatologist described the Veteran's vasculitis as "very complex and not completely understood." In a January 2012 progress note, the Veteran reported his rash "comes and goes," especially around the ankles. During a February 2012 VA skin examination, the Veteran reported three debilitating episodes in the past year due to urticaria (hives) and primary cutaneous vasculitis. The VA examiner described the Veteran's symptoms as a generalized rash with joint pain. The examiner noted the Veteran's vasculitis required intermittent systemic immunosuppressive therapy. The examiner opined the Veteran's vasculitis was not likely related to the 1978 left calf injury because vasculitis symptoms began in May 2011. Private treatment records reflect additional reports of flareups of vasculitis and cellulitis in May, July, and August of 2012. In an August 2012 clinic note, the attending clinician opined that the Veteran's cellulitis was not related to vasculitis, which "had not been very active over the past few years." A December 2012 record noted the Veteran's vasculitis was clinically inactive at that time. During a March 2020 VA arteries and veins examination, the Veteran continued to report that he contracted hepatitis C in service and later developed vasculitis. The VA examiner noted the Veteran was diagnosed with bilateral LCV in 2011 and had been treated for hepatitis C. However, on physical examination, the Veteran did not have vasculitis, any other rash, or external symptoms of hepatitis. The examiner indicated the Veteran had asymptomatic varicose veins but no other vascular conditions. The examiner explained that vasculitis is an inflammation of the blood vessels caused by the body's immune cells attacking blood vessels by mistake. She explained that vasculitis can be caused by an infection, medication, or other disease, however the cause is often unknown. The examiner noted that vasculitis can affect arteries, veins, and capillaries. She also noted the Veteran's vasculitis condition affected both legs and therefore was unlikely to have been caused by residuals of the 1978 left calf surgeries. In a September 2020 addendum opinion, the March 2020 VA examiner opined that the Veteran's vasculitis was not aggravated by his service-connected left calf injury residuals. On physical examination of the lower extremities, the examiner noted brisk capillary refill, palpable dorsalis pedis pulses, telangiectasia ("spider veins") in the left medial mid to posterior regions of the foot, brawny pigmentation without hair growth, and pitting edema. The examiner concluded that these symptoms were consistent with peripheral vascular disease, a separate condition. The examiner also noted the Veteran did not have visible vasculitis symptoms, including purpura (burst blood vessels), petechiae (round, rash-like spots caused by bleeding), ulcerations, nodules, warmth, or erythema/urticaria. The preponderance of the evidence is against finding that the Veteran's currently inactive vasculitis is related to service or caused and/or aggravated by his service-connected left calf laceration residuals. The medical evidence indicates that the Veteran developed an acute rash in 2011 that was eventually identified as vasculitis. As private medical providers noted at the time, his vasculitis condition was complex and not well understood. The March 2020 VA examiner explained that vasculitis affects the veins and is caused by infection or medication. She indicated that vasculitis was not present during the examination and the condition would not have been aggravated or caused by the Veteran's left leg laceration residuals. Additionally, the medical evidence indicates the Veteran's inactive vasculitis does not cause any occupational or other impairment. As the competent medical evidence indicates the Veteran's vasculitis is not related to his 1978 in-service leg injury/surgeries, or any associated residuals, the claim will be denied. To the extent the Veteran's private medical providers initially suggested a possible link between vasculitis and hepatitis C, the Board has denied service connection for hepatitis C. 38 C.F.R. § 3.310. As noted above, the hepatitis C virus has not been detected in the Veteran's blood since 2003. Without service connection for the underlying disability, secondary service connection must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert, above. 4. TDIU VA may assign a TDIU to veterans who are unable to secure or follow substantially gainful employment because of their service-connected disabilities. If there is only one service-connected disability, it must be rated 60 percent or more; if there are two or more disabilities, one disability must be rated 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). As of the date of this decision, the Veteran's service-connected disabilities include: an unspecified depressive disorder rated 50 percent disabling; recurrent cellulitis rated 30 percent disabling; left calf laceration residuals with nerve impairment rated 30 percent disabling; and left leg scars with two separate 10 percent ratings based on total affected area and one painful/tender scar. Since February 13, 2012, the Veteran's combined disability rating is 80 percent and his depressive disorder is rated 50 percent disabling. Therefore, he met schedular criteria for a TDIU as of February 13, 2012. The remaining question is whether his service-connected disabilities prevent him from securing substantially gainful employment. In his 2013 application for increased compensation based on unemployability, the Veteran reported he had not worked since May 2009. He reported he became too disabled to work since May 2011. The Veteran reported he was "self-taught" and had no formal education beyond high school. He reported working as a self-employed homebuilder from 2004 to 2009, but no other previous employment. During a December 2011 non-VA psychological evaluation, the Veteran reported extreme fatigue, mood swings, difficulty concentrating, constant worrying, low energy, sleep disturbance, racing thoughts, and difficulty completing tasks in a timely manner. A non-VA physician opined that the Veteran would be unable to complete a normal workday and work week without interruption from psychiatric symptoms and would not be able to cope with normal work stress. A February 2013 VA psychiatric examination report noted the Veteran's depressive disorder only caused "mild or transient symptoms" that decreased work efficiency and ability to perform occupational tasks. A September 2013 Social Security Administration (SSA) Disability Determination report indicated the Veteran was totally disabled since May 30, 2011. The SSA decision noted the Veteran's severe disabling impairments were vasculitis, an autoimmune disorder, Hepatitis C, a foot ulcer, depression and anxiety. The decision noted the Veteran had the capacity to perform sedentary work but lacked the capacity to work on a regular and continuing basis at any level of exertion. In a January 2015 mental health assessment, a non-VA psychologist opined that the Veteran could not sustain stress from a competitive work environment or be expected to engage in gainful activity due to his service-connected depressive disorder. The psychologist noted the Veteran had mild memory loss, difficulty adapting to stressful circumstances, and "near-continuous" depression and anxiety. She noted the Veteran's psychiatric symptoms were present at least since October 19, 2011. The Veteran reported needing some assistance with activities of daily living (ADLs) including food shopping, meal preparation, and cleaning. VA examinations in February 2012, March 2020, and September 2020 reflect that the Veteran' service-connected left calf laceration residuals with tibial nerve impairment, scarring, and cellulitis caused pain, weakness and fatigue that resulted in significant functional impairment, including difficulty walking, sitting, and standing. A June 2020 non-VA vocational assessment indicated that the Veteran has been unable to maintain substantial gainful employment at least since October 2011. The report noted the Veteran's occupational impairment was caused by both mental and physical limitations due to his service-connected depression and left leg disorders. The Board will grant a TDIU based on the benefit-of-the-doubt doctrine. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Hiaasen The Board's decision is only binding on this case. This action is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.