BVA9504405 DOCKET NO. 90-23 334 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUES 1. Entitlement to service connection for a deviated nasal septum. 2. Entitlement to service connection for a disability characterized by a positive tine tuberculin test. 3. Entitlement to an increased rating for arthritis of the right knee, currently evaluated as 10 percent disabling. 4. Entitlement to an increased rating for arthritis of the left knee, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Thomas A. Pluta, Counsel INTRODUCTION The veteran had active service from August 1957 to August 1987. This appeal originally arose from a May 1988 rating action of the Sioux Falls, South Dakota Regional Office (RO) which, in pertinent part, denied service connection for a low back disability, bilateral carpal tunnel syndrome, a bilateral elbow disability, a disability characterized by a positive tine tuberculin test, and a deviated nasal septum, and granted service connection for degenerative arthritis of both knees and the right wrist, rated as one entity and assigned a 20 percent rating, and hypertension, assigned a noncompensable evaluation. By rating action of October 1989, service connection was granted for degenerative arthritis of the low back and both elbows; these disabilities were added to the previously service-connected degenerative arthritic disease entity affecting both knees and the right wrist, and a 20 percent disability rating was continued. By rating action of May 1991, a 10 percent rating for hypertension was granted from March 1990; this constitutes a substantial grant of the benefit sought on appeal with respect to this issue. By decisions of February and October 1992, the Board of Veterans' Appeals (Board) remanded this case to the RO for additional development of the evidence. By rating action of February 1993, service connection for bilateral carpal tunnel syndrome was granted; this constitutes a substantial grant of the benefit sought on appeal with respect to this issue. The February 1993 rating action also assigned individual ratings under separate diagnostic codes for arthritis of the low back and each knee; the arthritis of the right wrist and both elbows remained rated as one entity. By decision of December 1993, the Board remanded this case to the RO for additional development of the evidence and for due process development. By rating action of February 1994, a 20 percent rating for arthritis of the low back was granted from September 1987. Individual ratings under separate diagnostic codes were also assigned for arthritis of the right wrist and each elbow, and 10 percent ratings for each of the latter disabilities was granted from September 1987; this constitutes a substantial grant of the benefit sought on appeal with respect to each of these issues. After developing additional evidence in this case, the Board, in accordance with Thurber v. Brown, 5 Vet.App. 119 (1993), informed the veteran's representative in a January 11, 1995, letter of the additional evidence developed, and provided an opportunity to respond. In a January 12, 1995, reply, the representative responded that he had nothing further to present. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends, in effect, that he currently suffers from a deviated nasal septum and a disability characterized by a positive tine tuberculin test which had their onset in service. He also asserts that his bilateral knee arthritis is more disabling than currently evaluated. DECISION OF THE BOARD In accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), following review and consideration of all evidence and material of record in the veteran's claims file, and for the following reasons and bases, it is the decision of the Board that the veteran has not met the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim for service connection for a disability characterized by a positive tine tuberculin test is well- grounded, and that the appeal with respect to that issue should, therefore, be dismissed; and that the preponderance of the evidence is against the claims for service connection for a deviated nasal septum and for an increased rating for arthritis of each knee. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. A deviated nasal septum was not noted on examination at entrance into service, but it is indisputable that such disability existed prior to service. 3. The veteran underwent a septectomy for deflection of the nasal septum in service to ameliorate a pre-existing disorder, and there was no pathological advancement of the basic, underlying pre-existing deviated nasal septum during service. 4. A disability characterized by a positive tine tuberculin test is not currently objectively demonstrated, and the claim for service connection is not plausible. 5. The veteran's arthritis of each knee is manifested by complaints of pain with activity, with minimal limitation of extension, mild limitation of flexion, some joint line tenderness and crepitus, and good ligamentous stability shown on recent U.S. Department of Veterans Affairs (VA) examinations, and has not resulted in marked interference with employment or required frequent periods of hospitalization. CONCLUSIONS OF LAW 1. A deviated nasal septum clearly and unmistakably existed prior to service, and the presumption of soundness on entrance into service is rebutted. 38 U.S.C.A. §§ 1111, 1137, 5107 (West 1991). 2. The veteran's pre-existing deviated nasal septum was not aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 1153, 5107 (West 1991); 38 C.F.R. § 3.306 (1993). 3. The veteran has not submitted evidence of a well-grounded claim with respect to the issue of entitlement to service connection for a disability characterized by a positive tine tuberculin test; thus, the Board does not have jurisdiction to adjudicate the claim. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303(b) (1993). 4. The veteran's arthritis of each knee is not more than 10 percent disabling. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 3.321(b)(1), Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, Part 4, Codes 5003, 5257, 5260, 5261 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection for a Deviated Nasal Septum We find that the veteran's claim is "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a). That is, we find that he has presented a claim which is plausible. We are also satisfied that all relevant facts have been properly developed, and that no further development is required to comply with the duty to assist the veteran mandated by 38 U.S.C.A. § 5107(a). Under the applicable criteria, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. A veteran who served during a period of war or during peacetime service after December 31, 1946 is presumed in sound condition except for defects noted when examined and accepted for service. Clear and unmistakable evidence that the disability manifested in service existed before service will rebut the presumption. 38 U.S.C.A. §§ 1111, 1137. The U.S. Court of Veterans Appeals (Court) has held that the presumption of soundness may be rebutted by clear and unmistakable evidence consisting of the veteran's own admissions during in-service clinical evaluations of a pre- service history of the disability for which service connection is claimed. Doran v. Brown, 6 Vet.App. 283 (1994). A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b). The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b)(1). The veteran has contended that he currently suffers from a deviated nasal septum which had its onset in service. However, the service medical records demonstrate that a deviated nasal septum, clinically manifested after entrance into service, indisputably existed prior to service, and was not aggravated thereby. A review of the service medical records discloses that the nose and sinuses were evaluated as normal on enlistment physical examination of July 1957. In September 1958, an over five-year history of difficult nose breathing and a running nose was noted. The Board notes that this would place the onset of a deviated nasal septum some four years prior to service. Current examination showed a markedly-deviated nasal septum to the left and injected mucosa. The impression was deviated nasal septum. On subsequent special examination, it was noted that the left nostril was practically blocked by septum deviation. A submucosal resection was felt to be the only possible treatment. In April 1959, the veteran was referred for evaluation of frequent nasal stuffiness. A submucous resection was noted to have been advised. Current examination showed left septal deviation on "an allergic nose." In August 1961, the veteran was hospitalized for an elective septectomy, submucous resection of the nasal septum, for deflection of the nasal septum. This was considered to have occurred in line of duty. In October 1961, the veteran was noted to have excellent airways bilaterally status post surgery, well-healed and symptomatically much improved. In a May 1965 report of medical history, the veteran reported a submucous resection at the age of 24. He denied current trouble with his nose, and the nose was normal on current examination. Examination of the nose in May 1968 was also negative. The veteran denied nose trouble in a March 1972 report of medical history. Examination of the nose in February 1975 was negative. The nose was also normal on examination of February 1976. The veteran again denied nose trouble in a March 1980 report of medical history, and the nose was normal on examination. On evaluation for allergies in February 1984, a past history of submucous resection of the nose in 1957 secondary to multiple fractured nasal bones was noted. On retirement physical examination of October 1984, the veteran was reported to have had a deviated nasal septum in adolescence. Current examination of the nose was normal. On another retirement physical examination in May 1987, the veteran was noted to have fractured both nasal clavicles at various times between 1949 and 1957; the Board notes that this history again points to the pre-service origin of nasal problems. Current examination of the nose was normal. On that record, the Board concludes that the veteran's deviated nasal septum existed prior to service, and that the presumption of soundness on entrance into service has been rebutted by clear and unmistakable evidence during the September 1958, October 1984, and May 1987 in-service clinical evaluations of a pre- service history of the disorder, noted above. Moreover, the septectomy the veteran underwent in service in August 1961 for deflection of the nasal septum was for the purpose of ameliorating the pre-existing disorder, and the record shows no increase in severity of the pre-service disability in service. On the contrary, the in-service record consistently shows marked improvement in nasal symptomatology status-post surgery. Clinical findings of October 1961 show that the veteran was symptomatically much improved status-post surgery, and numerous subsequent service medical records through the retirement physical examination in May 1987 consistently show a normal nose. Neither do the post-service records show increased severity of the pre-existing deviated nasal septum. On the contrary, the symptoms of the pre-existing disability have remained diminished from the pre-surgical September 1958 clinical findings in service showing practical blockage of the left nostril by septum deviation. Special VA examination in December 1987 showed that the nasal septum was in the mid-line, with only some very mild deflection to the left which was not felt to be significant. The impression was that the veteran's septum was basically within the mid-line and was not a factor in any breathing difficulty. On VA examination of July 1989, the nose had some septal deviation to the right, but the nasal airway was patent. On VA examination of the nose in April 1991, the septum was deviated to the left, and the airway was approximately 50 percent obstructed on the left; the Board notes that these symptoms are much less severe than the practical blockage of the left nostril noted in service in September 1958, prior to ameliorative surgery. As the preponderance of the evidence shows that a deviated nasal septum clearly and unmistakably existed prior to service and was not aggravated by service, the Board concludes that service connection for such disorder is not warranted. II. Service Connection for a Disability Characterized by a Positive Tine Tuberculin Test The threshold question to be answered in this case is whether the veteran has presented evidence of a well-grounded claim; that is, one which is plausible. If he has not presented a well-grounded claim, his appeal must fail, and there is no duty to assist him further in the development of his claim because such development would be futile. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet.App. 78 (1990). As will be explained below, we find that his claim is not well-grounded. The applicable criteria for the grant of service connection has been noted above. 38 U.S.C.A. §§ 1110, 1131. With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of pulmonary symptomatology in service will permit service connection of pulmonary disease, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or diagnoses including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). A review of the service medical records discloses that a chest X-ray on enlistment physical examination of July 1957 was negative, and the lungs and chest were normal on examination. In November 1958, the veteran was noted to have had contact with a tuberculosis patient. However, a current chest X-ray was normal, as were subsequent chest X-rays in March 1960 and November 1963. In a May 1965 report of medical history, the examiner noted that the veteran had lived with his father who had tuberculosis, but the veteran's X-rays were noted to have been always negative. The veteran specifically denied tuberculosis, and current examination of the lungs and chest was normal. A chest X-ray was negative. Medical records of January 1969 noted a positive tine tuberculin test in December 1968, with negative X-rays and one year of treatment with isoniazid was prescribed. A purified protein derivative test was positive, with a reaction of 13 millimeters. However, a chest X-ray was normal. A purified protein derivative test was again positive in March 1969. However, current examination of the chest was negative, and a chest X-ray was normal. The impression was tine and purified protein derivative converter. Chest X-rays in June 1969 were again normal. In January 1970, the veteran was noted to have completed one year of isoniazid treatment. In a March 1972 report of medical history, the veteran was noted to have lived with his father who had tuberculosis. A positive tine tuberculin test, a negative chest X-ray, and treatment with isoniazid were noted. The veteran denied tuberculosis. Current examination of the lungs and chest was normal, and a chest X-ray was negative. Numerous subsequent chest X-rays in service through 1983 continued to be negative. The veteran denied tuberculosis in reports of medical history in April and June 1984, and pulmonary function tests in May 1984 were normal. In July 1984, a purified protein derivative test was noted to be positive, but a chest X-ray was normal. On retirement physical examination of October 1984, the veteran was noted to have lived with a father who had tuberculosis and to have been a tuberculosis converter in 1970, treated with isoniazid therapy for one year. The veteran denied having tuberculosis, and current examination of the lungs and chest was normal. Moreover, chest X-rays and pulmonary function studies were normal. Essentially the same medical history and normal current respiratory findings were noted on another retirement physical examination in May 1987. A post-service December 1987 VA examination noted that the veteran's father had been treated for active tuberculosis when the veteran was in his early teen years. However, the veteran did not have a positive reaction until 1969, when he converted to positive by three different tests, though there was no X-ray evidence of pulmonary infection. He was given isoniazid for 1 year, and a September 1987 chest X-ray was reported to have been normal, as a result of which the current examiner did not repeat the chest X-ray. Current examination showed no abnormality to auscultation of the lung fields, and the veteran had no cough or respiratory distress. The diagnoses included positive tine tuberculin test with adequate treatment completed in 1970. The lungs were clear to auscultation and percussion on VA examination of July 1989, and a chest X-ray showed no pulmonary infiltrates. There were hilar calcifications with perihilar fibrosis. Numerous subsequent post-service military outpatient and VA medical records developed between 1989 and 1994 consistently show clear lungs and no respiratory pathology. On that record, the Board concludes that the in-service findings showing positive tine tuberculin and purified protein derivative skin tests in 1968 and 1969 implied no more than that the veteran was infected with tubercle bacilli, but these tests were not indicative of the presence of active tuberculous disease. See George M. Lordi and Lee B. Reichman, Tuberculin Skin Testing, in Tuberculosis 63-68 (D. Schlossberg ed., 3rd ed. 1994). Although the veteran was treated with medication (isoniazid) in service for positive findings stemming from having lived with his tuberculous father prior to service, he manifested no clinical or X-ray findings of tuberculous disease in service. Neither has any tuberculous disease been diagnosed post service. The Court has held that Congress specifically limited entitlement for a service-connected disease to cases where such incidents had resulted in a disability; in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet.App. 223 (1992). In the absence of a current objective demonstration of any respiratory disability attributable to the in-service findings of positive tuberculin skin testing, the Board concludes that the veteran has not met the initial burden of presenting evidence of a well-grounded claim imposed by 38 U.S.C.A. § 5107(a). In the absence of a well-grounded claim, there is no duty to assist him further in the development of the claim. Grottveit v. Brown, 5 Vet.App. 91 (1993). If a claim is not well-grounded, the Board does not have jurisdiction to adjudicate it. Boeck v. Brown, 6 Vet.App. 14 (1993). Accordingly, as a claim that is not well grounded does not present a question of fact or law over which the Board has jurisdiction, the appeal with respect to the claim for service connection for a disability characterized by a positive tine tuberculin test is dismissed. III. Entitlement to an Increased Rating for Arthritis of Each Knee, Each Currently Evaluated as 10 Percent Disabling We find that the veteran's claims are "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a). That is, we find that he has presented claims which are plausible. We are also satisfied that all relevant facts have been properly developed, and that no further development is required to comply with the duty to assist the veteran mandated by 38 U.S.C.A. § 5107(a). Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. §§ 4.1 and 4.2. Also, 38 C.F.R. § 4.10 provides that, in cases of functional impairment, evaluations must be based upon lack of usefulness of the affected part or systems, and medical examiners must furnish, in addition to the etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, full description of the effects of the disability upon the person's ordinary activity. These requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based upon a single, incomplete, or inaccurate report, and to enable the VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath, 1 Vet.App. at 594. In addition, 38 C.F.R. § 4.40 requires consideration of functional disability due to pain and weakness. As regards the joints, 38 C.F.R. § 4.45 notes that the factors of disability reside in reductions of their normal excursion of movements in different planes. The considerations include more or less movement than normal, weakened movement, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, swelling, deformity or atrophy of disuse, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. By rating action of May 1988, the RO granted service connection for degenerative arthritis of both knees and the right wrist, assigned a 20 percent rating from September 1987 under Diagnostic Code 5003 of the VA's Schedule for Rating Disabilities (38 C.F.R. Part 4) based on findings of arthritis in service and on post- service VA examinations of December 1987 and January 1988. By rating action of February 1993, individual ratings under separate Diagnostic Codes 5003-5257 were assigned for arthritis of each knee, each assigned a 10 percent rating from September 1987, based on findings of minimal limitation of motion on VA examination of February 1993. Under the applicable criteria, the evaluation of the same disability or manifestations under different diagnoses is to be avoided. 38 C.F.R. § 4.14 (1993). Rather, the veteran's disability will be rated under the diagnostic code which allows the highest possible evaluation for the clinical findings shown on objective examination. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. Part 4, Code 5003. Slight impairment of either knee, including recurrent subluxation or lateral instability, warrants a 10 percent evaluation. A 20 percent evaluation requires moderate impairment. 38 C.F.R. Part 4, Code 5257. Limitation of flexion of either leg to 45 degrees warrants a 10 percent evaluation. A 20 percent evaluation requires that flexion be limited to 30 degrees. 38 C.F.R. Part 4, Code 5260. Limitation of extension of either leg to 10 degrees warrants a 10 percent evaluation. A 20 percent evaluation requires that extension be limited to 15 degrees. 38 C.F.R. Part 4, Code 5261. After reviewing the entire evidence of record, the Board concludes that an evaluation in excess of 10 percent for either knee is not warranted. The veteran's complaints included knee pain on VA general medical examination of December 1987. A deep squat caused an audible pop in the right knee. The veteran could not go beyond a three-quarter squat on the left due to left knee pain. The veteran gave a history of arthroscopic surgery and removal of bone chips in December 1987, with improvement since that time. His greatest problem was a feeling of instability when descending stairs. His knees ached with activity. X-rays of both knees revealed degenerative changes with narrowing of the medial joint compartment. On special VA orthopedic examination in January 1988, the veteran's complaints included knee pain with sitting, stooping, standing and any activity that put pressure on the knees, such as ascending or descending stairs. There was no knee locking or catching. On examination, the veteran could touch his toes with ease. Sensory examination and reflexes were normal in the lower extremities. Knee range of motion was from 0 to 135 degrees, bilaterally. There was some mild instability to valgus stress at 20 degrees. There were marked subpatellar crepitus bilaterally and peripatellar tenderness, but no muscle wasting. The impressions included bilateral knee pain secondary to mild to moderate osteoarthritis. These findings correspond to no more than slight knee impairment under Diagnostic Code 5257, and clearly do not indicate moderate knee impairment, limitation of knee flexion to 30 degrees, or limitation of knee extension to 15 degrees which would entitle the veteran to a 20 percent rating under Diagnostic Codes 5257, 5260, or 5261, respectively. Military orthopedic clinical outpatient records of April 1989 show the veteran's complaints including right knee pain. However, there was good range of motion of the right knee on examination, with only mild pain to palpation. Although there was crepitus and X-rays showed further progression of degenerative changes, there was no effusion or instability. The assessment was degenerative joint disease of both knees. On VA orthopedic examination of July 1989, left knee arthroscopic surgery in December 1987 was noted to have helped the veteran's knee significantly. He still had some occasional catching and feeling of instability, and currently complained of constant bilateral knee pain, aggravated by increased activity. However, range of motion was from 0 to 135 degrees bilaterally on examination of the knees, and the ligaments were stable. There was some medial and lateral joint line discomfort. Those findings do not warrant a 20 percent evaluation under Diagnostic Codes 5257, 5260 or 5261. Military outpatient treatment records of June 1990 showed full range of motion of the right knee, and X-rays revealed generalized degenerative changes. The impression was degenerative arthritis of the right knee. On military physical examination for evaluation of polyarticular arthralgias in January 1991, the veteran gave a many-year history of increasing difficulty with the knees, with trouble going up and down stairs. However, prescribed medication was noted to be helpful, and he had no complaints of joint swelling. On examination, the veteran appeared to be very healthy. There were some crepitus over both knees and a mildly-positive patellar compression test, but there was no pain on palpation over the medial or lateral joint line. There was some very mild synovial proliferation over the right knee. Motor strength was 5/5. A review of X-rays revealed moderate degenerative changes involving both knees, with quite a bit of patellar femoral disease. There was no evidence of chondrocalcinosis. The impression was osteoarthritis, and the doctor speculated that the veteran's symptoms would slowly continue to progress. He recommended that the veteran do bicycling or swimming exercises to take pressure off joints affected by arthritis. A normal gait was noted on VA general medical examination of April 1991. Examination of the extremities revealed an 8-millimeter scar on the medial aspect of the left knee, the site of previous arthroscopic surgery. The veteran was noted to take prescribed medication to control his arthritis. Military outpatient treatment records of September 1991 show the veteran's complaints of right knee pain and trouble walking. Examination showed small effusion of the right knee, but all ligaments were intact. McMurray's sign was negative, and the assessment was knee pain. The examiner felt that this was probably a flare of arthritis. In December 1991, the veteran was seen with complaints of right knee pain and swelling after a fall on ice. Examination showed massive effusion and tenderness over the lateral patella. X-rays revealed internal progression of significant tricompartmental degenerative changes when compared with X-rays of five years ago. There was also a nondisplaced, longitudinally- oriented fracture through the lateral aspect of the patella. The assessment was fracture of the lateral patella, and knee immobilization was prescribed. VA X-rays of January 1993 revealed significant narrowing of the medial joint compartment of both knee joints. There were moderately-advanced degenerative arthritic changes involving the bony structures of both knee joints, but there was no evidence of fracture or dislocation. The Board notes this evidence that the veteran's December 1991 right patellar fracture had completely healed. On VA orthopedic examination of February 1993, it was noted that the veteran took prescribed medication for knee problems. On examination, the veteran was about 10 degrees short of full knee flexion. However, extension was full, and there was good ligamentous stability. McMurray's sign was negative. The examiner commented that the veteran's knees currently gave him only minimal discomfort, and it was felt that the bilateral knee degenerative changes seemed to be stable, without any acute injury or problem. X-rays revealed some degenerative changes, spurring, and calcification of the cartilage on both knees. These findings do not warrant a rating in excess of 10 percent under the criteria of Diagnostic Codes 5257, 5260 or 5261. On VA examination of January 1994, the veteran complained that his knees gradually became painful with use, and were worse and very painful after prolonged walking and standing. On examination, both knees appeared enlarged, and there was joint line tenderness of both knees, with crepitus palpable under the patellae. However, there was no palpable extra-articular fluid, and ligament support was firm in all directions. Right knee range of motion testing showed flexion to 115 degrees and extension to 170 degrees. Left knee range of motion testing showed flexion to 112 degrees and extension to 175 degrees. X-rays of both knees revealed narrowed medial joint compartments and moderately-advanced degenerative changes involving the bony structures, with no evidence of fracture or dislocation and no interval change from X-rays of a year ago. The diagnosis was advanced arthritic changes of both knees. These findings continue to show that the veteran's December 1991 right patellar fracture had completely healed. The clinical findings clearly do not show moderate impairment of either knee, limitation of knee flexion to 30 degrees, or limitation of knee extension to 15 degrees which would entitle the veteran to a 20 percent rating under Diagnostic Codes 5257, 5260 or 5261, respectively. Neither does the veteran's arthritis of either knee present such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. The veteran's work history does not indicate that his service-connected bilateral knee disorder was responsible for significantly impairing him industrially. On military physical examination of January 1991, the veteran was noted to be retired from work; no service-connected physical disability was noted to have caused his removal from the workplace. The veteran was noted to be currently attending college and pursuing studies toward completion of a degree. Moreover, the doctor's recommendation that the veteran do bicycling or swimming exercises to take pressure off arthritic joints is evidence that his knee arthritis would permit significant useful function of those extremities. On VA orthopedic examination of February 1993, the examiner commented that the veteran's knees currently gave him only minimal discomfort, and it was felt that the arthritic changes seemed to be stable, without any acute injury or problem. Neither does the record reflect frequent periods of hospitalization attributable to knee arthritis. Thus, the Board finds that an extraschedular evaluation for arthritis of either knee is not warranted. CONTINUED ON NEXT PAGE ORDER Service connection for a deviated nasal septum is denied. Evidence of a well-grounded claim not having been submitted with respect to the claim for service connection for a disability characterized by a positive tine tuberculin test, the appeal is dismissed. An increased rating for arthritis of each knee is denied. J. U. JOHNSON Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.