Citation Nr: 0000268 Decision Date: 01/05/00 Archive Date: 01/11/00 DOCKET NO. 95-34 630 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for allergic rhinitis and sinusitis. 2. Entitlement to service connection for a chronic gastrointestinal disorder. 3. Entitlement to service connection for a chronic headache disorder, including migraine headaches. 4. Entitlement to an evaluation in excess of 10 percent for chronic low back strain with degenerative changes. 5. Entitlement to an evaluation in excess of 10 percent for chondromalacia patella of the left knee. 6. Entitlement to an evaluation in excess of 10 percent for impingement syndrome of the left shoulder, status post arthroscopic surgery with degenerative changes. 7. Entitlement to an evaluation in excess of 10 percent for the residuals of right acromioclavicular separation, status post open reduction surgery with degenerative changes. 8. Entitlement to an evaluation in excess of 10 percent for chronic acne of the face, hands and arms. 9. Entitlement to a compensable evaluation for bursitis of both elbows. 10. Entitlement to a compensable evaluation for the postoperative residuals of surface squamous cell carcinoma of the right forehead. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant INTRODUCTION The veteran served on active duty from June 1973 to June 1993. This case was previously before the Board of Veterans' Appeals (Board) in April 1998, at which time it was remanded for additional development. Subsequent to the Board's remand, the Regional Office (RO), in a decision in May 1999, granted service connection (and a noncompensable evaluation) for bronchitis with asthma and emphysema. In that same rating decision, the RO granted a 10 percent evaluation for chronic low back strain with degenerative changes, and chondromalacia patella of the left knee. The veteran voiced his disagreement with the assignment of those evaluations, and the current appeal ensued. FINDINGS OF FACT 1. The veteran's current rhinitis and/or sinusitis as likely as not had their origin during the veteran's period of active military service. 2. The veteran's ulcer disease as likely as not had its origin during his period of active military service. 3. The claim for service connection for a chronic headache disorder, including migraine headaches, is not supported by cognizable evidence showing that such a disability was present in service, or is otherwise of service origin. 4. The veteran's service-connected low back strain with degenerative changes is currently productive of no more than slight limitation of motion of the lumbar segment of the spine, with characteristic pain on motion. 5. The veteran's service-connected chondromalacia of the left knee is currently productive of moderate impairment of that knee, with recurrent subluxation or lateral instability. 6. The veteran's service-connected impingement syndrome of the left shoulder is currently productive of no more than malunion of the clavicle or scapula, or nonunion without loose movement, accompanied by pain. 7. The veteran's service-connected residuals of right acromioclavicular separation are currently productive of no more than malunion of the clavicle or scapula, or nonunion without loose movement, accompanied by pain. 8. The veteran's service-connected acne of the face, hands, and arms is currently productive of no more than exfoliation, exudation, or itching involving an exposed surface or extensive area, with no evidence of marked disfigurement. 9. The veteran's service-connected bursitis of both elbows is at present essentially asymptomatic. 10. The veteran's service-connected residuals of surface squamous cell carcinoma of the right forehead consists of a scar which is neither tender nor painful on objective demonstration, or productive of any disfigurement. CONCLUSIONS OF LAW 1. Allergic rhinitis and sinusitis were incurred in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 1998); 38 C.F.R. § 3.102 (1998). 2. Duodenal ulcer disease was incurred in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 1998); 38 C.F.R. § 3.102 (1998). 3. The claim for service connection for a chronic headache disorder, including migraine headaches, is not well grounded. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1998). 4. An evaluation in excess of 10 percent for chronic low back strain with degenerative changes is not warranted. 38 U.S.C.A. § 1155 (West 1991 and Supp. 1998); 38 C.F.R. §§ 4.40, 4.45, 4.59, and Part 4, Codes 5292, 5293, 5295 (1998). 5. A 20 percent evaluation for chondromalacia patella of the left knee is warranted. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, and Part 4, Codes 5003, 5010, 5257 (1998). 6. An evaluation in excess of 10 percent for service- connected impingement syndrome of the left shoulder, status post arthroscopic surgery with degenerative changes, is not warranted. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. §§ 4.40, 4.45, 4.59, and Part 4, Codes 5003, 5010, 5203 (1998). 7. An evaluation in excess of 10 percent for service- connected residuals of right acromioclavicular separation, status post open reduction surgery with degenerative changes, is not warranted. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. §§ 4.40, 4.45, 4.59, and Part 4, Codes 5003, 5010, 5203 (1998). 8. An evaluation in excess of 10 percent for chronic acne of the face, hands, and arms is not warranted. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. Part 4, Codes 7800, 7806, 7819 (1998). 9. A compensable evaluation for bursitis of both elbows is not warranted. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. §§ 4.40, 4.45, 4.59, and Part 4, Codes 5019, 5206, 5207 (1998). 10. A compensable evaluation for the residuals of surface squamous cell carcinoma of the right forehead is not warranted. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. Part 4, Codes 7800, 7804, 7818 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Entitlement to Service Connection for Allergic Rhinitis/Sinusitis, a Chronic Gastrointestinal Disorder, and a Chronic Headache Disorder, Including Migraine Headaches As to those issues involving service connection, the threshold question which must be resolved is whether the veteran's claims are well grounded. See 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim is a plausible claim, meaning a claim which appears to be meritorious. See Murphy v. Derwinski, 1 Vet. App. 81. A mere allegation that disability is service connected is not sufficient; the veteran must submit evidence in support of his claim which would "justify a belief by a fair and impartial individual that the claims are plausible." 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for a claim to be well grounded, there must be competent evidence of current disability (medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the inservice injury or disease and the current disability (medical evidence). See Caluza v. Brown, 7 Vet. App. 498 (1995); see also Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); Heuer v. Brown, 7 Vet. App. 379 (1995); Grottveit v. Brown, 5 Vet. App. 91 (1993). The second and third elements of this equation may also be satisfied under 38 C.F.R. § 3.303(b) (1998) by (a) evidence that a condition was "noted" during service or during an applicable presumptive period; (b) evidence showing post-service continuity of symptomatology; and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology. See 38 C.F.R. § 3.303(b) (1998); Savage v. Gober, 10 Vet. App. 488 (1997). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of (i) the existence of a chronic disease in service or during an applicable presumptive period and (ii) present manifestations of the same chronic disease. Ibid. For the purpose of determining whether a claim is well grounded, the credibility of the evidence in support of the claim is presumed. See Robinette v. Brown, 8 Vet. App. 69 (1995). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 and Supp. 1998). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and ulcer disease becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1998); 38 C.F.R. §§ 3.307, 3.309 (1998). In the present case, the Board notes that, on a number of occasions in service, the veteran received treatment for headaches, variously classified as migraine or tension-type headaches. While on Department of Veterans Affairs (VA) general medical examination in July 1994, the veteran once again complained of headaches, classified as "tension cephalalgia," on subsequent VA neurologic examination in April 1995, the veteran voiced no complaints regarding headaches of any kind. Physical examination conducted at that time showed the veteran's head to be atraumatic and normocephalic. Cranial nerves II through XII were intact, and funduscopic evaluation showed the veteran to have flat discs bilaterally. In the opinion of the examiner, the veteran showed "normal" neurologic findings. The Board observes that, during the course of a VA gastrointestinal examination, likewise conducted in 1995, the veteran complained of "posterior neck tension headaches" which he had experienced over the past few months. However, a physical examination conducted at that time was essentially unremarkable, and no pertinent diagnosis was noted. On subsequent VA gastrointestinal examination in April 1999, the veteran denied the presence of headaches or dizziness, or of any weakness in his upper or lower extremities. As noted above, in order for a claim to be well grounded, there must, at a minimum, be competent evidence of current disability. See Caluza v. Brown, 7 Vet. App. 498 (1995). Absent evidence of a current chronic headache disorder, the veteran's claim for service connection is not well grounded, and must be denied. Turning to the issue of service connection for allergic rhinitis and/or sinusitis, the Board is of the opinion that the veteran's claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998). That is, he has presented a claim which is plausible. In that regard, service medical records disclose that, on numerous occasions in service, the veteran received treatment for and/or diagnoses of allergic rhinitis and sinusitis. Moreover, during the course of VA outpatient treatment in February 1994, shortly following the veteran's discharge from service, there was once again noted the presence of allergic rhinitis. On VA general medical examination in July 1994, the veteran complained of "nose and sinus allergies" for the past 10 years, for which he had received multiple medications. Physical examination revealed the presence of swollen nasal membranes and inflamed turbinates bilaterally, with postnasal drip in the posterior pharyngeal area. Additionally noted was that the veteran's nasal meatus could not be visualized due to the obstruction created by swelling of the turbinates. The pertinent diagnosis noted was allergic rhinitis and sinusitis. The Board observes that, in November 1994, the veteran was seen at a service medical facility with a complaint of, among other things, nasal congestion accompanied by a thick mucous drainage. Physical examination conducted at that time revealed some tenderness over the veteran's left maxillary sinus area, as well as a mild erythema of his throat. The clinical assessment was upper respiratory infection, clinical sinusitis. On VA fee-basis ear, nose, and throat examination in April 1995, the veteran complained of chronic sinus symptoms, including constant nasal congestion and a runny nose, with postnasal drainage. On physical examination, the veteran's septum was deviated to the right, and all turbinates, especially those on the left side, were markedly swollen. Sinus illumination was somewhat decreased symmetrically, although there was no evidence of any significant sinus tenderness. The Board notes that, on VA pulmonary examination in April 1995, the veteran once again gave a history of rhinitis and sinusitis. Complaints at that time included nasal congestion, and postnasal drip. Further evaluation revealed symptoms of active allergic rhinitis. The pertinent diagnosis was allergic rhinitis. The Board concedes that, notwithstanding the aforementioned clinical findings, recent radiographic studies of the veteran's sinuses have proved unremarkable. Nonetheless, given the veteran's long history of both rhinitis and sinusitis, the Board is of the opinion that each of those disabilities as likely as not had its origin during the veteran's period of active military service. Accordingly, a grant of service connection for allergic rhinitis and sinusitis is in order. Regarding the issue of service connection for a chronic gastrointestinal disorder, the Board is once again of the opinion that the veteran's claim is well grounded, in that it is plausible. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998). In that regard, over the course of the veteran's 20 years of active military service, he received treatment on a number of occasions for gastroenteritis, and on one occasion, for what was described at the time as duodenal ulcer disease. More specifically, following an upper gastrointestinal series in April 1991, there was noted a 5-millimeter prominence of the mucosal folds in the distal antrum of the veteran's stomach, with a collection of barium on the lesser curvature side in the immediate prepyloric region. The clinical assessment at that time was of a 5-millimeter lesser curvature prepyloric antral ulceration. On VA general medical examination in July 1994, there was some tenderness in the area of the right upper quadrant of the veteran's epigastric region. The pertinent diagnoses were duodenal ulcer; gastritis. The Board concedes that, since the time of the aforementioned VA general medical examination, there have been rendered somewhat conflicting opinions as to the nature and etiology of the veteran's claimed gastrointestinal pathology. In that regard, while on VA gastrointestinal examinations in February 1995 and December 1998, there was essentially no evidence of any chronic gastrointestinal pathology, on VA examination in March 1996, the veteran received a diagnosis not only of duodenal ulcer disease, but also of gastritis with gastroesophageal reflux disease. Moreover, while on recent VA gastrointestinal examination in January 1999, the veteran received a diagnosis of chronic gastroesophageal reflux, rule out Barrett's esophagus, a subsequent addendum to that examination noted that, while the veteran had been thought to have chronic esophageal reflux and Barrett's esophagus, a recent upper gastrointestinal series had revealed no evidence of gastroesophageal reflux. Based on the aforementioned, it would appear that the veteran currently experiences no chronic, clinically-identifiable gastrointestinal pathology. Nonetheless, as previously noted, the veteran has in fact received a diagnosis of duodenal ulcer disease, a pathology which, by definition, is considered to be chronic. 38 C.F.R. § 3.309 (1998). Inasmuch as the veteran's ulcer disease was first shown to be present in service, the Board is of the opinion that such residuals as the veteran may experience as a result of that pathology likewise had their origin in service. Accordingly, a grant of service connection for the residuals of ulcer disease is warranted. II. Entitlement to Increased Evaluations for Chronic Low back Strain with Degenerative Changes; Chondromalacia Patella of the Left Knee; Impingement Syndrome of the Left Shoulder; Residuals of Right Acromioclavicular Separation; Acne of the Face, Hands, and Arms; Bursitis of Both Elbows; and Residuals of Surface Squamous Cell Carcinoma of the Right Forehead As regards the veteran's claims for increased ratings, the Board notes that disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the rating schedule. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. Part 4 (1998). In evaluating the severity of a particular disability, it is essential to consider its history. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1, 4.2 (1998). However, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the reported history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board further notes that it is the intent of the Schedule for Rating Disabilities (Part 4) to recognize painful motion with joint or periarticular pathology as productive of disability. 38 C.F.R. § 4.59 (1998). This is to say that, even absent a definable limitation of motion, where there is functional disability due to pain, supported by adequate pathology, compensation may be warranted. 38 C.F.R. §§ 4.40, 4.45 (1998). Regarding the veteran's claim for an increased evaluation for his service-connected low back disorder, the Board notes that, on VA orthopedic examination in July 1994, the veteran complained of intermittent and episodic low back pain, with a "catch" in his low back about the lumbosacral and left or right iliolumbar areas, though with no associated numbness, tingling, or weakness in the lower extremities. According to the veteran, his "attacks" occurred approximately once or twice a year, with very little if any low back complaints between those attacks. On physical examination, the veteran's low back motion was "good and complete." In the opinion of the examiner, the veteran experienced "no impairment" of his lower back due to motor restriction. Nor did he show any evidence of sensory or motor radiculopathy. On more recent VA orthopedic examination in January 1999, the veteran stated that he experienced "constant back pain" which was somewhat worse in the morning and late afternoon, and which was "relieved" when he "got up and walked around." Additionally noted was that, since the time of the veteran's discharge from service, he had been working in landscaping, with the result that his back had "gotten worse." On physical examination, there was no evidence of any tenderness or deformity of the veteran's back. His gait was within normal limits, and there was no evidence of spasm. Range of motion measurements showed forward flexion to 90 degrees, with lateral bending to 20 degrees, and rotation to 25 or 26 degrees in either direction. The veteran was able to arise without difficulty, and to hyperextend to approximately 18 to 20 degrees without pain. Straight leg raising was negative at 90 degrees. The veteran displayed a good sensation to light touch in his lower extremities, as well as excellent strength in the major motor groups of his lower extremities. Reflexes were two-plus and bilaterally equal at both the knee and ankle. Radiographic studies showed some minor degenerative changes with questionable disc space narrowing at the level of the 4th and 5th lumbar vertebrae. The clinical impression was of chronic low back pain, with a history of back pain, and no evidence of radicular or significant degenerative disease at the present time. The Board observes that the 10 percent evaluation currently in effect contemplates the presence of slight limitation of motion of the lumbar segment of the spine, accompanied by characteristic pain on motion. 38 C.F.R. Part 4, Codes 5293, 5295 (1998). In order to warrant an increased evaluation, there would, of necessity, need to be demonstrated the presence of moderate limitation of motion of the lumbar segment of the spine, or, in the alternative, moderate recurring intervertebral disc syndrome, or lumbosacral strain characterized by muscle spasm on extreme forward bending and a unilateral loss of lateral spine motion in the standing position. 38 C.F.R. Part 4, Codes 5292, 5293, 5295 (1998). As is clear from the above, the veteran currently exhibits no such clinical manifestations. More specifically, he currently experiences no more than a slight limitation of motion of his lumbar spine, with no evidence of muscle spasm, or of radicular or significant degenerative disease. Under such circumstances, the Board is of the opinion that the 10 percent evaluation currently in effect is appropriate, and that an increased rating is not warranted. Turning to the issue of an increased rating for service- connected chondromalacia patella of the left knee, the Board notes that, at the time of the aforementioned VA orthopedic examination in July 1994, the veteran complained of some "snapping and popping" in his left knee, with pain over the medial joint line and, to some extent, the peripatellar area, but no severe swelling. Physical examination revealed a good range of motion (0 through 130 degrees) of the veteran's left knee, as well as good stability of the anterior and posterior cruciate ligaments, and of the medial and lateral collateral ligaments. There was no rotator instability, and patellofemoral tracking was considered to be good. At the time of examination, there was no evidence of any effusion of the veteran's left knee, and no particular crepitus. Some tenderness was present over the medial joint line, as well as on rotation of the tibia externally on the femur. On more recent VA orthopedic examination in January 1999, the veteran complained of diffuse pain, particularly when getting up out of the kneeling or sitting position. According to the veteran, his left knee "constantly popped," and would occasionally lock," as well as swell on an intermittent basis. On physical examination, there was two-plus effusion as well as medial joint line tenderness of the veteran's left knee. McMurray's sign was negative, and the veteran's left knee was stable. Further examination revealed tenderness with patellofemoral compression, in conjunction with 0 to 130 degrees of flexion. The veteran's quadriceps strength was felt to be good in spite of an old ruptured quadriceps tendon. In the opinion of the examiner, the veteran experienced "significant problems" with his knees, as characterized by frequent swelling. While this might be due to chondromalacia patella or, in the alternative, a torn cartilage, "either way, there were significant problems both subjectively and objectively" in both of the veteran's knees. The Board observes that the 10 percent evaluation currently in effect for the veteran's service-connected left knee disability contemplates the presence of slight impairment of that knee, with recurrent subluxation or lateral instability. In order to warrant an increased evaluation, there would, of necessity, need to be demonstrated the presence of moderate left knee impairment, or a limitation of flexion to 30 degrees, and/or a limitation of extension to 15 degrees. 38 C.F.R. Part 4, Codes 5257, 5260, 5261 (1998). An increased evaluation would, likewise, be in order were there to be malunion of the tibia and fibula, with moderate knee or ankle disability. 38 C.F.R. Part 4, Code 5262 (1998). As is clear from the above, the veteran does not currently exhibit a limitation of flexion or extension sufficient to warrant an increased evaluation. Nonetheless, based upon a review of the pertinent evidence of record, the Board is of the opinion that current manifestations of the veteran's service-connected left knee disability more nearly approximate the criteria for a 20 percent evaluation than the 10 percent evaluation currently in effect. 38 C.F.R. § 4.7 (1998). This is particularly the case given the recent evidence of two-plus effusion in the veteran's left knee, accompanied by tenderness in the medial joint line and on patellofemoral compression. Under such circumstances, a 20 percent evaluation for the veteran's service-connected chondromalacia patella of the left knee is in order. 38 C.F.R. Part 4, Codes 5257, 5262 (1998). An evaluation in excess of 20 percent is not warranted, however, inasmuch as the veteran does not currently exhibit the marked knee or ankle disability, or severe impairment of the left knee requisite to the assignment of such an evaluation. Regarding the issues of increased evaluations for the veteran's service-connected right and left shoulder disabilities, the Board notes that, on VA orthopedic examination in July 1994, the veteran complained of some stiffness in his right shoulder, as well as occasional aching with prolonged overhead use of his right arm, and on certain extremes of motion. Reportedly, the veteran's right shoulder condition had been "pretty stable" over the past few years, though in the last month or two, he had experienced some increased discomfort on abduction and external rotation in the subacromial interval. As regards his left shoulder, the veteran complained of a chronic tendinitis and subacromial bursitis, which had been treated conservatively with injections and other physical modalities. Reportedly, the veteran had in the past experienced intractable discomfort, with the result that, in 1993, just prior to his discharge from service, he underwent an open decompression of the left shoulder with anterior acromioplasty and debridement of the subacromial space. Since that time, the veteran had experienced a definite reduction of pain, though with continued popping and a sense of discomfort at certain extremes of abduction and external rotation. On physical examination, the veteran exhibited a high-riding right clavicle which was relatively nontender. There was a full range of motion, though with pain at the extremes. Scap-thoracic motion was likewise good, and within normal limits. Glenohumeral motion was 85 to 90 percent of normal. The veteran's left shoulder showed no evidence of any high- riding acromioclavicular joint or lateral clavicle. Once again, there was good range of motion, though with slight tenderness over the anterior subacromial interval. There was no evidence of atrophy, and scap-thoracic and glenohumeral motion were good. On more recent VA orthopedic examination in January 1999, the veteran complained of painful motion in his left shoulder. Physical examination revealed 175 degrees of flexion, with 145 degrees of abduction, 65 degrees of extension, and external rotation of 40 degrees. Internal rotation was to T8. At the time of evaluation, there was no evidence of any deformity of the veteran's left shoulder, and his muscle strength was good. The clinical impression was status post decompression of the left shoulder, with good result. As regards the veteran's right shoulder, it was noted that he had experienced an acromioclavicular separation, for which he had received treatment with an open reduction and internal fixation. Reportedly, the screw which had been inserted during the course of the aforementioned surgery was later removed. The veteran's complaints included some decreased range of motion, as well as fatigability in his right shoulder. On physical examination, there was present a rather large anterior scar, with some acromioclavicular subluxation. Radiographic studies were described as "about a second degree." There was no evidence of any tenderness in the acromioclavicular joint. Range of motion studies showed flexion to 107 degrees, with abduction to 150 degrees, and 65 degrees of extension. External rotation was to 65 degrees, and the veteran was able to internally rotate his right shoulder to T12. Muscle strength was described as good. Radiographic studies showed a second degree acromioclavicular separation, with calcified acromioclavicular ligaments, representative of healing. The clinical impression was of status post acromioclavicular dislocation with repair and average results. Noted at the time of evaluation was that the veteran might experience some discomfort with "overhead work." The Board notes that the veteran in this case is, by clinical studies, right-handed. In order to warrant an increased evaluation for his service-connected right or left shoulder disabilities, there would, of necessity, need to be demonstrated the presence of a limitation of motion of the veteran's right or left arm at shoulder level, or nonunion of the clavicle or scapula, with loose movement or dislocation. 38 C.F.R. Part 4, Codes 5201, 5203 (1998). As noted above, the veteran experiences a relatively good range of motion of both his right and left shoulders. Under no circumstances is his right or left arm movement limited to shoulder level. Nor are there clinical manifestations approximating nonunion of the clavicle or scapula, accompanied by loose movement. Under such circumstances, the Board is of the opinion that the respective 10 percent evaluations currently in effect for the veteran's service-connected right and left shoulder disabilities are appropriate, and that increased ratings are not warranted. Turning to the issue of a compensable evaluation for the veteran's service-connected bursitis of both elbows, the Board notes that, on VA orthopedic examination in July 1994, the veteran complained of left elbow pain. Reportedly, the veteran had experienced a left lateral epicondylitis about his elbow, which had been treated with injections, and a "tennis elbow splint." According to the veteran, his left elbow problems tended to recur with heavy activity. On physical examination, the veteran displayed good elbow, hand, and wrist motion. There was some tenderness over the lateral epicondyle area of the veteran's elbow, though reflexes were equal. Sensation and strength were likewise equal, as were the circumferences of the upper extremities. As of the time of a recent VA orthopedic examination in January 1999, the veteran complained of "tennis elbow" on one side only. Reportedly, the veteran had received injections, and had been given a brace, with the result that he now experienced only "minimal symptoms, in spite of his work as a landscaper." On physical examination, the veteran's right elbow showed no atrophy, tenderness, or pain with resistant extension. Range of motion studies showed 90 degrees of pronation and supination, as well as flexion from 0 to 130 degrees. At the time of evaluation, there was no evidence of fluid in either of the veteran's elbow joints. The veteran's left elbow was described as "exactly the same" as his right, and radiographic studies of each elbow were within normal limits. Noted at the time of examination was that, while the veteran might have had a tennis elbow in the past, he currently had "normal X-rays and normal findings." The Board observes that, in order to warrant a compensable evaluation for service-connected bursitis of both elbows, there would, of necessity, need to be demonstrated limitation of flexion of the forearm to at least 100 degrees, or of extension to 45 degrees. 38 C.F.R. Part 4, Codes 5019, 5206, 5207 (1998). Clearly, the veteran currently exhibits no such limitation of motion. Moreover, as of the time of the most recent orthopedic examination in January 1999, there was no evidence of pain in either of the veteran's elbows. Based on such findings, the Board is of the opinion that the noncompensable evaluation currently in effect for the veteran's service-connected bursitis of both elbows is appropriate. Accordingly, an increased rating is not warranted. Turning to the issue of increased evaluations for the veteran's service-connected acne of the face, hands, and arms, and squamous cell carcinoma of the right forehead, at the time of the aforementioned VA general medical examination in July 1994, the veteran gave a history of chronic acne, for which he took medication, as well as actinic keratosis, and cancer of the forehead. Physical examination revealed the presence of actinic keratoses of the forehead and temple area, as well as of the scalp, and both arms. On VA fee-basis dermatologic examination, likewise conducted in July 1994, it was noted that the veteran had experienced considerable exposure to sunlight over the years, with most related damage occurring around his forehead, face, and neck. In addition, the veteran had reportedly undergone removal of a skin cancer from his right forehead. According to the veteran, his service-connected acne was "not so much of a problem" as the recurrent keratoses and history of skin cancer and the "obvious skin damage on his face." On physical examination, there was a scarring lesion on the veteran's left forehead. On the left lower nasolabial fold, there was a small nodular lesion measuring approximately 2 to 3 millimeters in diameter resembling a basal cell epithelioma. The veteran, however, maintained that this would probably subside "after a while." Other areas of the veteran's face were characterized by redness and scaling, as well as obvious actinic damage. With the exception of one small actinic keratosis on the exterior surface of his left forearm, the veteran's trunk and arms were relatively clear. There was a minimal degree of change on the dorsal surface of the veteran's hands, as evidenced by patches of hyperpigmentation and scaling, as well as one lesion on the left hand which had recently been irritated. On more recent VA dermatologic examination in February 1999, the veteran gave a history of basal cell carcinoma of the forehead, which had been excised in the 1980's. Additionally noted was the presence of a 5 cc left nasolabial fold which had been excised in 1997. At the time of evaluation, the veteran gave a 20-plus-year history of multiple macular erythematous lesions of his face and arms. Physical examination revealed the presence of multiple erythematous lesions of the face and forearms, some of which were hypertrophic. There was no evidence of any ulcers, though some of the aforementioned lesions were crusted. At the time of evaluation, there was no evidence of any associated systemic or nervous manifestations. The pertinent diagnosis was actinic keratoses of the face and forearms. The Board observes that the 10 percent evaluation currently in effect for the veteran's service-connected acne of the face, hands, and arms contemplates the presence of exfoliation, exudation or itching involving an exposed surface or extensive area. In order to warrant an increased evaluation, there would need to be demonstrated the presence of constant exudation or itching, as well as extensive lesions, or marked disfigurement. 38 C.F.R. Part 4, Codes 7806, 7819 (1998). In like manner, a compensable evaluation for the veteran's service-connected scar as the residual of excision of squamous cell carcinoma of the right forehead would require demonstrated evidence of tenderness and/or pain of the scar in question, or some evidence of disfigurement of the veteran's face. 38 C.F.R. Part 4, Codes 7800, 7804, 7818 (1998). However, as is clear from the above, the veteran currently exhibits no such clinical manifestations. Indeed, as of the time of the aforementioned VA dermatologic examination in February 1999, there was no evidence of the constant exudation or itching, or extensive lesions or marked disfigurement requisite to the assignment of an increased evaluation for service-connected acne. Nor was there any evidence that the scar of the veteran's forehead sustained as the result of the surgical excision of squamous cell carcinoma was either tender or painful, or productive of any disfigurement. Under such circumstances, the Board is of the opinion that the respective schedular evaluations currently in effect for the veteran's service-connected acne of the face, hands, and arms, and squamous cell carcinoma of the right forehead are appropriate, and that increased ratings are not warranted. In reaching the above determinations, the Board has given due consideration to the veteran's testimony given at the time of an RO hearing in January 1996. Such testimony, however, as regards all issues save those of service connection for allergic rhinitis/sinusitis and ulcer disease, and an increased evaluation for service-connected chondromalacia patella of the left knee, is regrettably not probative when taken in conjunction with the entire objective medical evidence presently on file. The Board does not doubt the sincerity of the veteran's statements. Those statements, however, in and of themselves, do not provide a persuasive basis for a grant of the benefits sought in light of the evidence as a whole. ORDER Service connection for allergic rhinitis and sinusitis is granted. Service connection for the residuals of ulcer disease is granted. Service connection for a chronic headache disorder, including migraine headaches, is denied. An evaluation in excess of 10 percent for chronic low back strain with degenerative changes is denied. An increased (20%) evaluation for service-connected chondromalacia patella of the left knee is granted, subject to those regulations governing the award of monetary benefits. An evaluation in excess of 10 percent for impingement syndrome of the left shoulder, status post arthroscopic surgery with degenerative changes, is denied. An evaluation in excess of 10 percent for the residuals of right acromioclavicular separation, status post open reduction surgery with degenerative changes, is denied. An evaluation in excess of 10 percent for chronic acne of the face, hands, and arms is denied. A compensable evaluation for bursitis of both elbows is denied. A compensable evaluation for the residuals of surface squamous cell carcinoma of the right forehead is denied. S. F. SYLVESTER Acting Member, Board of Veterans' Appeals