Citation Nr: 0000955 Decision Date: 01/12/00 Archive Date: 01/27/00 DOCKET NO. 98-04 938 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for chondromalacia of the right knee. 2. Entitlement to service connection for a bilateral foot disorder. 3. Entitlement to service connection for major depressive disorder. 4. Entitlement to service connection for alopecia (claimed as hair loss due to undiagnosed illness). 5. Entitlement to service connection for seborrheic dermatitis (claimed as skin disorder due to undiagnosed illness). 6. Entitlement to service connection for laryngitis and sore throats (claimed as flu-like symptoms due to undiagnosed illness). 7. Entitlement to service connection for sinus disorder due to undiagnosed illness. 8. Entitlement to service connection for sore gums due to undiagnosed illness. 9. Entitlement to service connection for muscle soreness due to undiagnosed illness. 10. Entitlement to service connection for hemorrhoids. 11. Entitlement to service connection for thyroid disorder due to undiagnosed illness. 12. Entitlement to service connection for sleep disturbance with fatigue due to undiagnosed illness. 13. Entitlement to service connection for vaginal infections due to undiagnosed illness. 14. Entitlement to service connection for joint pain due to an undiagnosed illness. 15. Entitlement to an increased evaluation for duodenitis with small ulcer disease currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. L. Mason, Associate Counsel INTRODUCTION The veteran had active service from October 1980 to February 1981 and in the Persian Gulf from October 1990 to May 1991. This case comes to the Board of Veterans' Appeals (Board) on appeal from an October 1997 rating decision of the Jackson, Mississippi Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for chondromalacia of the right knee and pes planus, status post surgery for hammertoe deformity; service connection for major depressive disorder (claimed as depression), alopecia, seborrheic dermatitis (claimed as skin disorder), history of laryngitis and sore throats (claimed as flu-like symptoms), a sinus disorder, sore gums, muscle soreness, sleep disturbance with fatigue, hemorrhoids, a thyroid disorder, vaginal infections, and joint pain all claimed as due to undiagnosed illness. The RO also denied an evaluation in excess of 10 percent for duodenitis with small ulcer and an evaluation in excess of 30 percent for headaches. In an April 1998 rating decision, the RO increased the evaluation for headaches to 50 percent. The veteran, in a May 1998 statement, indicated that she agreed with the increased evaluation for headaches, but continued to disagree with remaining denials and requested that her file be kept open as to such illnesses. As the veteran has indicated her satisfaction with the increased evaluation of headaches, that issue is no longer before the Board. See Fenderson v. West, 12 Vet. App. 119 (1999). Preliminary review of the record reveals that the RO expressly considered referral of the veteran's claim for an increased evaluation for his duodenitis with small ulcer to the VA Undersecretary for Benefits or the Director, VA Compensation and Pension Service for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1999). The RO did not find that this case presents 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 United States Court of Appeals for Veterans Claims (Court) has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (1999) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. VAOPGCPREC 6-96 (1996). The issue of service connection for joint pain and the increased rating issue are addressed in the remand appended to this decision. FINDINGS OF FACT 1. Chondromalacia of the right knee is attributable to service. 2. Pes planus is attributable to service. 3. Competent medical evidence showing a nexus between the veteran's status post bilateral hammertoe deformities and her active service is not of record. 4. Competent medical evidence showing a nexus between the veteran's ganglion cyst of the left foot and her active service is not of record. 5. Service connection is currently in effect for headaches. 6. The veteran's major depressive disorder has been etiologically related to her service-connected headaches. 7. The veteran's hair loss has been attributed to the known clinical diagnosis of alopecia, and there is no competent medical evidence of record showing a nexus between the veteran's alopecia and her active service. 8. The veteran's skin rash has been attributed to the known clinical diagnoses of contact and seborrheic dermatitis, and there is no competent medical evidence of record showing a nexus between the veteran's seborrheic dermatitis and her active service. 9. The veteran's flu-like symptoms have been attributed to upper respiratory infections, allergic vasomotor rhinitis, a sore throat and laryngitis, and there is no competent medical evidence of record showing a nexus between the veteran's upper respiratory infections, allergic vasomotor rhinitis, sore throat and laryngitis and her active service. 10. There is no competent medical evidence of record showing a nexus between the veteran's sinus disorder and her active service. 11. There is no competent medical evidence of record showing that the veteran has a chronic disability causing sore gums or that there is a nexus between the veteran's claimed sore gums and her active service. 12. There is no competent medical evidence of record showing a nexus between the veteran's muscle soreness and her active service. 13. There is no competent medical evidence of record showing a nexus between the veteran's hemorrhoids and her active service. 14. There is no competent medical evidence of record showing a nexus between the veteran's thyroid disorder and her active service. 15. Competent evidence does not indicate that the veteran currently has a sleep disorder that was incurred or aggravated during, or as a result of service, or that she manifests a chronic fatigue disability due to an undiagnosed illness. 16. Competent medical evidence of vaginal infections due to undiagnosed illness is not of record. CONCLUSIONS OF LAW 1. Chondromalacia of the right knee was incurred in service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.303(b) (1999). 2. Pes planus was incurred in service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.303(b) (1999). 3. The veteran's claim of entitlement to service connection for status post bilateral hammertoe deformities is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 4. The veteran's claim of entitlement to service connection for ganglion cyst of the left foot is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 5. Major depressive disorder has been found to be proximately due to or the result of a service-connected disease or injury. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310(a) (1999). 6. The veteran's claim of entitlement to service connection for hair loss due to undiagnosed illness (now diagnosed as alopecia) is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 7. The veteran's claim of entitlement to service connection for a skin disorder due to undiagnosed illness (now diagnosed as seborrheic dermatitis) is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 8. The veteran's claim of entitlement to service connection for flu-like symptoms due to undiagnosed illness (now diagnosed as upper respiratory infection, allergic vasomotor rhinitis, and sore throat) is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 9. The veteran's claim of entitlement to service connection for a sinus disorder as due to undiagnosed illness is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 10. The veteran's claim of entitlement to service connection for sore gums as due to undiagnosed illness is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 11. The veteran's claim of entitlement to service connection for muscle soreness as due to undiagnosed illness is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 12. The veteran's claim of entitlement to service connection for hemorrhoids is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 13. The veteran's claim of entitlement to service connection for a thyroid disorder is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 14. The veteran's claim of entitlement to service connection for sleep disturbance with fatigue due to undiagnosed illness is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 15. The veteran's claim of entitlement to service connection for vaginal infections due to undiagnosed illness is not well grounded. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that the issues of entitlement to service connection for hair loss due to undiagnosed illness (diagnosed as alopecia), flu-like symptoms due to undiagnosed illness, joint pain due to undiagnosed illness, sore gums due to undiagnosed illness, and muscle soreness due to undiagnosed illness were denied in a July 1994 rating decision. However, subsequent to this decision, the law and regulations pertaining to Persian Gulf War veterans was changed. Accordingly, the RO reopened these claims. The veteran is seeking service connection for a right knee disorder, a foot disorder, depression, alopecia (claimed as hair loss), seborrheic dermatitis (claimed as skin disorder), history of laryngitis and sore throats (claimed as flu-like symptoms), a sinus disorder, sore gums, muscle soreness, sleep disturbance with fatigue, hemorrhoids, a thyroid disorder, vaginal infections, and joint pain, all claimed as due to undiagnosed illness. It is necessary to determine if she has submitted a well grounded claim with respect to each issue. In making a claim for service connection, the veteran has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a). A well grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well grounded claim for service connection generally requires competent evidence of a current disability; proof as to incurrence or aggravation of a disease or injury in service, as provided by either lay or medical evidence, as the situation dictates; and competent evidence as to a nexus between the inservice injury or disease and the current disability. Cohen v. Brown, 10 Vet. App. 128, 137 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995) aff'd per curiam, 78 F.3d 604 (Fed.Cir. 1996) (table); see also 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303 (1996); Layno v. Brown, 6 Vet. App. 465 (1994); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Alternatively, the nexus between service and the current disability can be satisfied by evidence of continuity of symptomatology and medical or, in certain circumstances, lay evidence of a nexus between the present disability and the symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495 (1997). Moreover, establishing a well grounded claim for service connection for a particular disability requires more than an allegation that the particular disability had its onset in service. It requires evidence relevant to the requirements for service connection cited above and of sufficient weight to make the claim plausible and capable of substantiation. Tirpak v. Derwinski, 2 Vet. App. 609 (1992); see also Murphy, 1 Vet. App. at 81. An injury during service may be verified by medical or lay witness statements; however, the presence of a current disability requires a medical diagnosis; and where an opinion is used to link the current disorder to a cause during service, a competent opinion of a medical professional is required. Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991). 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 a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). The Secretary of VA may pay compensation to a Persian Gulf veteran exhibiting objective indications of chronic disability resulting from a chronic illness or combination of undiagnosed illnesses that became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more before December 31, 2001 following such service. See 38 U.S.C.A. § 1117 (West 1991 & Supp. 1999); 38 C.F.R. § 3.317 (1999). According to 38 C.F.R. § 3.317(a)(2), objective indications includes both signs in the medical sense of objective evidence perceptible to an examining physician and other non- medical indicators capable of independent verification. While objective indications appears to contemplate evidence other than the veteran's own statements, the veteran's own statements concerning non-medical indicators may be sufficient if such indicators are reasonably capable of independent verification. See VAOPGCPREC 4-99 (1999). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317 (1999). As noted above, 38 C.F.R. § 3.317 states that VA shall pay compensation to a Persian Gulf veteran who exhibits "objective indications of chronic disability." That section further states that "[f]or purposes of this section, 'objective indications of chronic disability' include both 'signs', in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification." 38 C.F.R. § 3.317. The VA general counsel has determined that many of the signs or symptoms appear to be susceptible to lay observation by the veteran or other persons, obviating the need for medical evidence. However, the general counsel further found that the manifestation of one or more signs or symptoms of undiagnosed illness require some objective indication of the presence of a chronic disability attributable to an undiagnosed illness before awarding compensation. See VAOPGCPREC 4-99 (1999). Compensation shall not be paid if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. The veteran has not alleged that she served in combat and the evidence of record does not indicate that she served in combat. Thus, 38 U.S.C.A. § 1154(b) (West 1991) is not applicable in this case. A. Right knee Service medical records from the veteran's first period of service from October 1980 to January 1981 show no complaints, findings, or treatment of a right knee disability. Service medical records reveal that the veteran was seen in February 1991 complaining of right knee pain following an injury to the right knee. On evaluation, there was slight swelling and medial tenderness. The diagnosis was right knee medial contusion. Medical records indicate that the veteran was again seen in March 1991 complaining of knee trauma after twisting her right knee. The assessment was right knee strain. At her April 1991 redeployment examination just prior to separation, an evaluation of the lower extremities was normal. At a November 1993 VA examination, the veteran complained of intermittent episodes of pain in her right knee with increased discomfort with prolonged standing or walking. The examiner noted that the veteran had an injury to her left knee in service. On evaluation, range of motion of the right knee was 0 to 145 degrees without redness, heat, swelling, or crepitus. There was no tenderness to palpation and no instability. X-rays of the knees revealed a very faint small lucent area in the right proximal tibia on its medial aspect although the significance of this was unclear could represent an artifact. The impression included history of recurrent right knee pain, uncertain etiology. An April 1994 VA medical record shows that the veteran was seen complaining of pain and giving out of the right knee. The veteran reported injuring the right knee in April 1991. On evaluation, the right knee was tender posteriorly and in the lateral aspects of the popliteal space. The examiner reported that extension of the knee was limited to 45 degrees secondary to pain. There was no swelling or deformity. The impression included knee sprain, questionable meniscal injury. A May 1994 VA medical record reveals that the veteran was complaining of pain in the anterior knee with swelling. On evaluation, the patella was boggy with no effusion, there was no tenderness at the inferior pole patella, and range of motion was full. The impression was patella tendonitis on the right. X-rays of the right knee revealed mild narrowing involving the medial joint compartment of the right knee. At a July 1997 VA examination, the veteran complained of intermittent symptomatic right knee with pain. On evaluation, range of motion of the right knee was 0 to 140 degrees. There was slight crepitus, popping, and mild tenderness of the patella-femoral joint on range of motion. There was no redness, heat, swelling, or instability. X-rays revealed a normal right knee. The impression included chondromalacia patella of the right knee with history of blunt trauma. The Board has reviewed the probative evidence of record including the veteran's medical records and statements on appeal. The clinical record establishes that the veteran was diagnosed with right knee medial contusion and right knee strain during service. VA medical records from 1994 to 1997 show complaints of right knee pain with diagnoses including right knee sprain, patellar tendonitis, and chondromalacia of the right knee. In light of such evidence and given the absence of competent evidence to the contrary, the Board concludes that service connection is warranted for chondromalacia patella of right knee. B. Bilateral foot disorder At the veteran's October 1980 enlistment examination, the evaluation of the feet was normal. Service medical records from the veteran's first period of service from October 1980 to January 1981 shows that the veteran was seen for a sprain of the left foot. Poor medial ankle alignment was noted. The assessment included pes planus and poor medial ankle alignment. At the January 1981 examination, the veteran complained of foot trouble; however, evaluation of the feet was normal. In an October 1990 report of individual medical history, there were no complaints, findings, or diagnosis of any disability of the feet. A late October 1990 service medical record revealed that the veteran was seen complaining of right arch pain. There was tenderness to palpation at the right medial arch with mild edema in the right instep. Flexible pes planus was noted as was medium plantar fasciitis. The veteran was placed on physical profile for right arch strain. At the April 1991 examination, the veteran complained of foot trouble and flexible flat feet was diagnosed. An August 1991 VA record shows that the veteran complained of a bump on the left foot. An asymptomatic ganglion cyst in the exterior digit was diagnosed. In a March 1995 letter, M.B.P., a Doctor of Podiatry Medicine, reported that he has seen the veteran since November 1994 for hammertoes, bump on the top of her left foot, and flat feet. She underwent corrective surgery for hammertoes bilaterally. It was recommended that she obtain a pair of orthotics. Dr. P also stated that the veteran has a flat foot disorder. He further indicated that the cyst on her left foot is a possible subsequent condition secondary to her decreased arches bilaterally. Dr. P indicated that he could not substantiate that her boots caused either of these conditions. At a July 1997 VA examination, the veteran reported that she has flat feet and had surgery for bilateral hammertoes. She reported pain with prolonged periods of weightbearing. On evaluation, grade I pes planus was noted. There was no plantar tenderness or pain on manipulation of the feet. Examination of the toes revealed small well-healed scars across the dorsal aspect of the distal interphalangeal joints of the 2nd, 3rd, and 4th toes bilaterally. There was full range of motion of the toes. The impression included history of bilateral hammertoe deformities, postoperative. With respect to the veteran's claim for flat feet, the Board has reviewed the probative evidence of record including the veteran's medical records and statements on appeal. The clinical record establishes that the veteran was diagnosed with pes planus and flexible flat feet during service. VA and private medical records from 1995 to 1997 show findings of pes planus and bilateral flat feet. In light of such evidence and given the absence of competent evidence to the contrary, the Board concludes that service connection is warranted for bilateral pes planus. However, the Board finds that the veteran's claim for bilateral hammertoe deformities and ganglion cyst of left foot are not well grounded. See Caluza, supra. The veteran is competent to report that on which she has personal knowledge, that is what comes to her through her senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board has carefully considered the veteran's statements with respect to this claim; however, through her statements alone, she cannot meet the burden imposed by section 5107(a) merely by presenting her lay statements as to the existence of a disease and a relationship between that disease and her service because lay persons are not competent to offer medical opinions. Espiritu, 2 Vet. App. 492. Consequently, lay assertions of medical etiology or diagnosis cannot constitute evidence to render a claim well grounded under section 5107(a); if no cognizable evidence is submitted to support the claim, the claim cannot be well grounded. Tirpak, 2 Vet. App. at 611. However, the Court has held that where the issue involves medical causation, competent medical evidence which indicates that the claim is plausible or possible is required to set forth a well grounded claim. Grottveit, 5 Vet.App. at 93. In the instant case, there is no competent medical evidence linking the veteran's status post bilateral hammertoe deformities to the veteran's period of active service. Additionally, although a private physician stated that there was a possibility the cyst was related to her decreased arch, he did not provide any reasons for such conclusion. Accordingly, the Board concludes that the veteran's claim for service connection for status post bilateral hammertoe deformities and cyst of the left foot are not well grounded and is denied. C. Depression Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1999). The Court has clarified that service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service-connected disorder has aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection is currently in effect for headaches. The veteran's service medical records make no reference to a depressive disorder. At a September 1991 VA examination for compensation purposes, the veteran complained of nervousness. At that time, the examiner evaluated the veteran's headache disorder. The diagnosis was normal neurological examination with tension or muscle contraction headaches. VA medical records from April 1991 to September 1991 show that the veteran was seen complaining of severe debilitating headaches every day lasting from 15 to 45 minutes, which began during her active service in January 1991. These records contain references to diagnoses of posttraumatic stress disorder (PTSD). However, a September 1991 evaluation indicates that the veteran does not meet the PTSD criteria. She also reported daily anxiety episodes coincided with peak period of headache. It was noted that she described significant symptoms of depression, including irritability, preoccupation with health, sleep disturbances, concentration difficulties, decreased energy, and social withdrawal. On evaluation, the veteran's mood was depressed and her affect constricted. There was no evidence of delusions or hallucination, although she did note transient auditory experiences. The conclusion was that the veteran met the criteria for chronic paroxysmal hemicrania. A January 1994 VA medical record noted that the veteran was hospitalized for her headache disorder. Sad expression was noted and her mood was described as giving up. She reported that she slept a lot and was uncomfortable around people. The impression was dysthymia. VA medical records from July to August revealed that the veteran complained of poor sleep, worsening headache control, and decreased energy. Her mood and affect were depressed. The impression was dysthymia. A December 1995 VA medical record revealed that the veteran was seen complaining of typical migraine and was tearful. She reported difficulty with nerves. The impression was headache/anxiety depressive disorder. VA medical records from January to October 1996 show continued complaints of headaches with episodes of depression. The impressions included major depressive disorder by history, migraine by history, and rule out PTSD. In an October 1996 Medical Board Evaluation for U.S. Army Reserves, the veteran reported that she only has depression when she has headaches. It was noted that she had been diagnosed with major depressive disorder, dysthymia, psychosis, and personality disorder. The examiner noted that the veteran had a history of intractable headaches. The diagnoses were mood disorder due to medical condition with depressive features and pain disorder associated with psychological factors and general medical condition. The examiner noted that the veteran had marked impairment for military duty as well as considerable impairment for social and industrial adaptability. The Medical Evaluation Board found that the veteran's mood disorder due to medical condition with depressive features had an approximate date of origin in 1991, the same time of the veteran's headaches and that the mood disorder was incurred in the line of duty (LOD). Subsequent VA medical records show continued treatment for major depressive disorder. The Board has reviewed the probative evidence of record including the veteran's statements on appeal. The claim for service connection for a depressive disorder is well grounded. The veteran is service connected for a headache disorder and in October 1996, the Department of the Army determined that the veteran's depressive disorder was associated with the headache disorder. This determination was based on review of VA medical records as well as a Medical Evaluation Board. Accordingly, the Board concludes that the preponderance of evidence supports entitlement to service connection for a depressive disorder. D. Alopecia Service medical records show no complaints, finding, or diagnoses of hair loss during service. There were no complaints, findings, or diagnoses of hair loss at the time of her April 1991 service redeployment examination. A September 1991 VA examination only contains complaints of a rash of the face. A November 1993 VA examination with photographs shows that the examiner found bitemporal alopecia. In a January 1994 VA medical record, the veteran complained that her hair falls out and grows back very slowly. The assessment was to evaluate the veteran for antidepressant medication. Subsequent VA medical records and VA examinations contain no complaints, findings, or diagnoses of hair loss or alopecia. Because the veteran's hair loss has been attributed to a known clinical diagnosis, 38 C.F.R. § 3.317 does not apply. Upon review of the evidence, the Board notes that the veteran contended that she had hair loss which has not been diagnosed and she believed it developed as a result of her service in the Gulf in 1991. However, in this case, the veteran's hair loss has been attributed to alopecia. The record therefore establishes that the veteran has a diagnosed condition and that the hair loss is not attributable to any undiagnosed illness. Additionally, the Board notes that such diagnosis has not been related to the veteran's active service. While the veteran has alleged that her hair loss is due to her active service in support of the Persian Gulf War, in the absence of evidence demonstrating that she has the requisite training to proffer medical opinions, her contentions are no more than unsubstantiated conjecture and are of no probative value. See Moray v. Brown, 5 Vet.App. 211 (1993). The Board has carefully considered the veteran's statements with respect to her claim; however, through her statements alone, she cannot meet the burden imposed by section 5107(a) merely by presenting her lay statements as to the existence of a disease and a relationship between that disease and her service because lay persons are not competent to offer medical opinions. Espiritu, 2 Vet. App. 492. Consequently, lay assertions of medical etiology or diagnosis cannot constitute evidence to render a claim well grounded under section 5107(a); if no cognizable evidence is submitted to support the claim, the claim cannot be well grounded. Tirpak, 2 Vet. App. at 611. Accordingly, the Board concludes that this claim is not well grounded and thus, is denied. E. Skin rash disorder At her April 1991 redeployment examination, the veteran reported experiencing skin disease during service. Her service medical records, however, show no findings or diagnoses of skin disorder during service. An April 1991 evaluation of the skin was normal. At a September 1991 VA examination, the veteran complained of a rash of the face. On evaluation, history of skin rash of face was noted; however, the skin was clear. The diagnosis included history of rash of face, clear now. A May 1991 VA medical record indicated that the veteran complained of a rash on her face. On examination, there was a slight decrease in pigmentation without erythema or lesions on the forehead, nose and beneath the eye. The diagnosis was hypopigmentation, questionable tinea versicolor. VA examinations performed in November 1993 and July 1994 contain no complaints, findings, or diagnoses of a skin rash disorder. An April 1994 VA medical record indicates that the veteran complained of skin rash on arms. It was noted that the veteran's child had the same rash. The assessment was possible contact dermatitis or photosensitivity. Hydrocortisone cream gave relief. At a July 1997 VA examination, the veteran reported that she had a rash on her face since 1991 when she was in Desert Storm. Photographs were taken. The examiner indicated that the veteran's arms, legs, and trunk were examined as well. Post inflammatory hyperpigmentation was noted. The examiner opined that the rash was probably seborrheic dermatitis, but that it was inactive. Subsequent VA medical records from October 1997 to February 1998 do not show complaints, findings, or diagnosis of any skin rash disorder. As noted above, because the veteran's skin rash has been attributed to a known clinical diagnosis, 38 C.F.R. § 3.317 does not apply. Upon review of the evidence, the Board notes that the veteran contended that she had a skin rash which has not been diagnosed and she believed it developed as a result of her service in the Gulf in 1991. However, in this case, the veteran's skin rash has been attributed to contact dermatitis and seborrheic dermatitis. The record therefore establishes that the veteran has a diagnosed condition and that the skin rash is not attributable to any undiagnosed illness. Additionally, the Board notes that such diagnosis has not been related to the veteran's active service. While the veteran has alleged that her skin rash disorder is due to her active service in support of the Persian Gulf War, in the absence of evidence demonstrating that she has the requisite training to proffer medical opinions, her contentions are no more than unsubstantiated conjecture and are of no probative value. See Moray, 5 Vet.App. 211. The Board has carefully considered the veteran's statements with respect to her claim; however, through her statements alone, she cannot meet the burden imposed by section 5107(a) merely by presenting her lay statements as to the existence of a disease and a relationship between that disease and her service because lay persons are not competent to offer medical opinions. Espiritu, 2 Vet. App. 492. Consequently, lay assertions of medical etiology or diagnosis cannot constitute evidence to render a claim well grounded under section 5107(a); if no cognizable evidence is submitted to support the claim, the claim cannot be well grounded. Tirpak, 2 Vet. App. at 611. Accordingly, the Board concludes that this claim is not well grounded and thus, is denied. F. Flu-like symptoms/Sinus disorder Service medical records show no complaints, findings, or treatment of flu-like symptoms or a sinus disorder during service. Service medical records do indicate that the veteran was seen complaining of a sore throat. The assessment was sore throat, viral syndrome. At her April 1991 redeployment examination, there were no complaints of sore throat or laryngitis. Evaluations of the nose, sinuses, mouth and throat were normal. A September 1992 VA medical record revealed that the veteran was seen with a mild cold and sniffles. On examination, there was left frontal tenderness less in the maxillary area. The assessment was questionable sinus component with tenderness versus hyperpathia secondary to headaches. At a November 1993 VA examination, the veteran reported that she has laryngitis and a cold continuously, with four or five episodes per year. On evaluation, an intermittent dry cough was noted. The mouth and pharynx were benign and the neck was supple without adenopathy. Lungs were clear to auscultation and percussion without rales, rhonchi, or wheezes. The diagnoses included history of upper respiratory infections. At a July 1997 VA examination, the veteran complained of flu- like symptoms, consisting of losing her voice about once a year, and frontal and generalized headaches. She reported being diagnosed with strep throat and viral infection in the past and a history of sinus trouble, which was described as nose stuffiness with little drainage. On evaluation of the lymphatic system, no adenopathy was noted. The external paranasal sinus and nasal structure were within normal limits, no nasal discharge, polyps, lesions, or other abnormalities. The parasinuses were negative. The septum was moderately deviated and the turbinates were mild to moderately hyperemic. On evaluation of the respiratory system, she denied experiencing a cough and had no history of shortness of breath. Her lungs were clear to auscultation and percussion without rales, rhonchi, or wheezes. On evaluation of the nose and sinuses, the oral cavity, pharynx, larynx, and neck were all within normal limits. The examiner noted that the veteran had symptoms and findings consistent with allergic vasomotor rhinitis, and there was no other ear, nose, and throat pathology. A December 1997 VA medical record shows that the veteran complained of cold symptoms for two weeks, including frequent cough, night sweats, fever, and sore throat. She reported that she gets a cold once a year since 1991. The veteran stated that she was told she had strep throat several weeks ago. On examination, she coughed through the exam, throat was red with patchy discoloration, and there was a low grade fever. There was no adenopathy, no sinus tenderness, and no polyps. The lungs were clear to auscultation. The assessment was upper respiratory infection with low grade fever. As noted above, because the veteran's complaints of flu-like symptoms and sinus disorder have been attributed to known clinical diagnoses including upper respiratory infection and allergic vasomotor rhinitis, thus 38 C.F.R. § 3.317 does not apply. Therefore, the record establishes that the veteran has a diagnosed condition and that the flu-like symptoms and sinus disorder are not attributable to any undiagnosed illness. Additionally, the Board notes that such diagnoses have not been related to the veteran's active service. While the veteran has alleged that her flu-like symptoms and sinus disorder are due to her active service in of the Persian Gulf, in the absence of evidence demonstrating that she has the requisite training to proffer medical opinions, her contentions are no more than unsubstantiated conjecture and are of no probative value. See Moray, 5 Vet.App. 211. The Board has carefully considered the veteran's statements with respect to her claim; however, through her statements alone, she cannot meet the burden imposed by section 5107(a) merely by presenting her lay statements as to the existence of a disease and a relationship between that disease and her service because lay persons are not competent to offer medical opinions. Espiritu, 2 Vet. App. 492. Consequently, lay assertions of medical etiology or diagnosis cannot constitute evidence to render a claim well grounded under section 5107(a); if no cognizable evidence is submitted to support the claim, the claim cannot be well grounded. Tirpak, 2 Vet. App. at 611. Accordingly, the Board concludes that these claims are not well grounded and thus, are denied. G. Sore gums Service medical records do not contain complaints, findings, or diagnosis of sore gums. At her April 1991 redeployment examination, the veteran did not complain of sore gums and an evaluation of the mouth was normal. A November 1993 VA dental examination showed fair oral hygiene with head and neck findings within normal limits. VA medical records from March 1995 to April 1995 indicate that the veteran was seen complaining of sensitive teeth with pain on chewing. She reported that she had dental work performed. The assessment was exacerbation of headaches secondary to dental issues. At an August 1997 VA dental examination, the veteran complained of sore gums and sensitive teeth, which she reported began in 1992 after her return from the Persian Gulf. On evaluation, the right and left lateral excursions, vertical excursions, protrusive excursions of the mandible were without symptoms and within normal limits. There was no displacement of the mandible on closure. There was no soreness or tenderness of the extra- oral or intra-oral muscles of mastication on palpation. The examiner stated that he was unable to diagnosis any of the claimed symptoms to exist and that in general, the veteran had normal dentition. The veteran is competent to report on that which she has personal knowledge, that is what comes to her through her senses. Layno, 6 Vet. App. at 470. Although she is competent to report that she has sore gums, she is not competent to establish the diagnoses. She cannot meet the burden imposed by section 5107(a) merely by presenting her lay statements as to the existence of a disorder and a relationship between that disorder and her service, additional objective evidence, whether medical or non- medical, is required. 38 C.F.R. § 3.317 (1999). At this time, there is no competent evidence that the veteran has gum disease or infection. In addition, there is no competent evidence that links the claimed condition to service. The veteran's claim for service connection for gum soreness is not well grounded. See Caluza, supra. In the absence of proof of a current disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The veteran's assertion that he has a gum disorder or infection is not competent and does not establish a well grounded claim. Chelte v. Brown, 10 Vet. App. 268 (1997). As there is no competent evidence of current diagnosis of a gum disease or infection, the Board concludes that the veteran's claim for service connection for soreness of gums due to an undiagnosed illness is not well grounded and is denied. H. Muscle soreness Service medical records do not contain complaints, findings, or diagnosis of sore muscles. At her April 1991 redeployment examination, the veteran did not complain of sore muscles and an evaluation of the musculoskeletal system was normal. At a November 1993 VA examination, the veteran complained of muscle soreness in her left upper arm. On evaluation, there was slight tenderness to palpation of the left upper arm. The diagnosis was subjective muscle soreness of the left upper arm, etiology unknown. However, private and VA medical records, prior and subsequent to this diagnosis show that the veteran had normal muscle tone and strength with no atrophy, fasciculation or abnormal movements and there were no diagnoses related to muscle soreness. The veteran is competent to report that on which she has personal knowledge, that is what comes to her through her senses. Layno, 6 Vet. App. at 470. As noted above, the veteran's own statements, in some cases, concerning non- medical indicators may be sufficient if such indicators are reasonably capable of independent verification. VAOPGCPREC 4-99 (1999). However, she cannot meet the burden imposed by section 5107(a) merely by presenting her lay statements as to the existence of a disorder and a relationship between that disorder and her service because lay persons are not competent to offer medical opinions. Espiritu, 2 Vet. App. 492. In the instant case, there is no competent medical evidence linking muscle soreness to her active military service. Moreover, muscle soreness of the left arm was found only in November 1993, there have been no other findings of signs or symptoms of such either prior to November 1993 examination or subsequent thereto. Thus, the requirement of the existence of a disability for 6-months has not been met. Accordingly, the Board concludes that the veteran's claim for service connection for muscle soreness is not well grounded and is denied. I. Hemorrhoids Service medical records do not contain complaints, findings, or diagnosis of hemorrhoids. At her April 1991 redeployment examination, the veteran did not complain of hemorrhoids and an evaluation of the anus and rectum was normal. At a September 1991 VA examination, an evaluation of the digestive system was negative. There was no organomegaly, no masses, and no tenderness, and bowel sounds were nonreactive. At a November 1993 VA examination, there were no complaints of hemorrhoids, but she did complain of diarrhea. Bowel sounds were normoactive and there was no rebound tenderness. During a December 1995 hospitalization at a VA Medical Center (VAMC), the veteran was evaluated for hematochezia and a sigmoidoscopy was performed. The impression was internal hemorrhoids. At a July 1997 VA examination, the veteran complained of hemorrhoids. On evaluation, the bowel sounds were normoactive and there was no rebound tenderness. There were external hemorrhoid tags. The examiner noted that the veteran reported that she had not had any problems with hemorrhoids for approximately one month and only had problems when she was constipated. The diagnoses included hemorrhoids. As noted above, the veteran's hemorrhoids have been attributed to known clinical diagnosis of hemorrhoids, 38 C.F.R. § 3.317 does not apply. Moreover, the Board finds that the veteran's claim for service connection for hemorrhoids is not well grounded. While the veteran has alleged that her hemorrhoids are due to her active service in support of the Persian Gulf War, in the absence of evidence demonstrating that she has the requisite training to proffer medical opinions, her contentions are no more than unsubstantiated conjecture and are of no probative value. See Moray, 5 Vet.App. 211. The Court has held that where the issue involves medical causation, competent medical evidence which indicates that the claim is plausible or possible is required to set forth a well grounded claim. Grottveit, 5 Vet.App. at 93, Espiritu, 2 Vet. App. 492. Consequently, lay assertions of medical etiology or diagnosis cannot constitute evidence to render a claim well grounded under section 5107(a); if no cognizable evidence is submitted to support the claim, the claim cannot be well grounded. Tirpak, 2 Vet. App. at 611. In the instant case, there is no competent medical evidence linking the veteran's hemorrhoid disorder to her active service. Accordingly, the Board concludes that the veteran's claim for service connection for hemorrhoids is not well grounded and is denied. J. Thyroid disorder Service medical records do not contain complaints, findings, or diagnosis of a thyroid disorder. At her April 1991 redeployment examination, the veteran did not complain of a thyroid disorder and an evaluation of the endocrine system was normal. VA medical records from October 1991 to November 1991 contain findings of mild thyromegaly, asymptomatic and no nodules per scan. An October 1997 VA medical record shows that the veteran was evaluated for thyroid disorder. Margin notes indicated that a September 1997 work-up indicated a slightly enlarged thyroid gland. The examiner noted that over the past 3 years, the veteran was positive for tremors, nervousness, anxiety and palpations. She had lost 5 lbs. since last year. Her appetite was fair and she complained of fatigue and tiredness. On evaluation, her thyroid gland was slightly enlarged and diffusely soft. The impression was possible mild hyperthyroidism, questionable Graves disease. A December 1997 VAMC discharge summary indicated while the veteran was hospitalized for depression and headaches, she was also evaluated for her thyroid. A T3 uptake and T4 came back normal with decreased thyroid stimulating hormone. A February 1998 VA medical record shows weight loss, nervousness, and palpations. The assessment was clinically hyperthyroid. As noted above, because the veteran's a thyroid disorder, which she attributed to an undiagnosed illness incurred during the Persian Gulf War, has been diagnosed as hyperthyroidism, a known clinical diagnosis, 38 C.F.R. § 3.317 does not apply. Moreover, the Board finds that the veteran's claim for service connection for hyperthyroidism is not well grounded. While the veteran has alleged that her hyperthyroidism is due to her active service in support of the Persian Gulf War, in the absence of evidence demonstrating that she has the requisite training to proffer medical opinions, her contentions are no more than unsubstantiated conjecture and are of no probative value. See Moray, 5 Vet.App. 211. The Court has held that where the issue involves medical causation, competent medical evidence which indicates that the claim is plausible or possible is required to set forth a well grounded claim. Grottveit, 5 Vet.App. at 93, Espiritu, 2 Vet. App. 492. Consequently, lay assertions of medical etiology or diagnosis cannot constitute evidence to render a claim well grounded under section 5107(a); if no cognizable evidence is submitted to support the claim, the claim cannot be well grounded. Tirpak, 2 Vet. App. at 611. In the instant case, there is no competent medical evidence linking the veteran's hyperthyroidism to her active service. Accordingly, the Board concludes that the veteran's claim for service connection for a thyroid disorder, diagnosed as hyperthyroidism, is not well grounded and is denied. K. Sleep disturbance with fatigue After reviewing the evidence of record, the Board finds that there is no competent evidence linking any current complaints of sleep disturbance with fatigue to service or to an undiagnosed illness. Although sleep disturbance and fatigue have been noted in VA medical records and VA examinations from 1994 to 1998, these records indicate that such complaints were symptoms of the veteran's hyperthyroidism and service-connected major depressive disorder. With respect to the veteran's allegations that she suffers from fatigue and insomnia due an undiagnosed disability that had its onset in the Persian Gulf, the Board notes that the symptomatology of which the veteran has complained has not resulted in a disability which can be said to be undiagnosed. As noted above, because the veteran's sleep disturbance and fatigue have been attributed the veteran's diagnosed hyperthyroidism and major depressive disorder, known clinical diagnoses, 38 C.F.R. § 3.317 does not apply. Furthermore, the Board has previously addressed these disabilities. Accordingly, the Board concludes that the veteran's claim for service connection for sleep disturbance with fatigue as a result of an undiagnosed illness is not well grounded and is denied. L. Chronic vaginal infections Service medical records from the veteran's first period of active service from October 1980 to January 1981 show no complaints, findings, or diagnoses of vaginal infections. A July 1985 service record indicated that the veteran was seen complaining of vaginal itching with discharge while on duty. Vaginal infection was noted. However, the record does not contain documentation that the veteran was on active duty at this time. Subsequent service medical records from the veteran's period of active service from October 1990 to April 1991 does not reveal any findings or treatment for vaginal infections. At her April 1991 redeployment examination, the veteran reported that she was treated for vaginitis during deployment with some return of symptoms; however, a pelvic examination was normal. On August 1994 gynecological examination for VA, the veteran reported a history of recurrent vaginal infections for 6 years, usually a yeast infection. On evaluation, all findings were normal. The diagnosis was recurrent yeast infection by history. The examiner was unable to assess if currently had a yeast infection because of veteran's menses. VA medical records prior to and subsequent to this examination do not reveal complaints, findings, or treatment of vaginal infections. The veteran is competent to report on that which she has personal knowledge, that is what comes to her through her senses. Layno, 6 Vet. App. at 470. While the veteran has alleged that her vaginal infections are due to her active service in the Persian Gulf, in the absence of evidence demonstrating that she has the requisite training to proffer medical opinions, her contentions are no more than unsubstantiated conjecture and are of no probative value. See Moray, 5 Vet.App. 211. However, her statement that her vaginal infections are related to her service in the Persian Gulf cannot serve to well ground the claim because the veteran is not competent to make such an allegation, as this requires competent medical evidence which indicates that the claim is plausible or possible. Caluza, 7 Vet. App. at 507; see also Robinette, 8 Vet. App. at 77; Edenfield, 8 Vet. App. 384; Grottveit, 5 Vet. App. at 93. In the instant case, the veteran claims service connection for chronic vaginal infection as due to undiagnosed illness. In fact, a diagnosis has been made, namely recurrent yeast infections. Accordingly, the Board finds that the recurrent vaginal infections cannot be said to be due to undiagnosed illness. Her military medical records reflect treatment for one episode of vaginitis during summer training in 1985. It is unclear when the infection began. According to reliable medical history, she was treated for another episode while she was on active duty in 1990-1991. That she has suffered from recurrent episodes of vaginal infection is made clear from the history she provided on examination in August 1994. Significantly, however, she did not date the onset of these infections to any period of service, either active duty or active duty for training, but simply reported the onset in approximately 1988. Also of significance, there is no medical opinion providing a nexus between the recurrent vaginal infection and service. Accordingly, the claim for service connection for the vaginal infection disorder, either on a direct or presumptive basis, is not well grounded, and must be denied. 38 U.S.C.A. § 5107 (West 1991). ORDER Service connection for chondromalacia of the right knee is granted. Service connection for pes planus is granted. Service connection for status post bilateral hammertoe deformities is denied. Service connection for a ganglion cyst of the left foot is denied. Service connection for major depressive disorder is granted. Service connection for alopecia (claimed as hair loss due to undiagnosed illness) is denied. Service connection for a skin rash disorder due to undiagnosed illness (now diagnosed as contact dermatitis or seborrheic dermatitis) is denied. Service connection for flu-like symptoms due to undiagnosed illness (now diagnosed as upper respiratory infection, allergic vasomotor rhinitis, and sore throat) is denied. Service connection for a sinus disorder is denied. Service connection for sore gums is denied. Service connection for muscle soreness is denied. Service connection for hemorrhoids is denied. Service connection for a thyroid disorder including hyperthyroidism, is denied. Service connection for sleep disorder with fatigue is denied. Service connection for vaginal infections due undiagnosed illness is denied. REMAND With respect to the claim for service connection for joint pain, it appears from the more recent assertions by the veteran that she is confining the claim to symptomatology affecting the hands. For example, on the last VA examination of her joints in July 1997, she referred only to history of pain and swelling of the fingers of both hands. The impression was intermittent pain and swelling of the fingers of both hands per history, examination unremarkable at this time. When she underwent VA examination in November 1993 VA examination, she had complained of pain in the right index finger and thumb, and the impression was tenderness and slight swelling of the proximal interphalangeal joint of the right index finger, uncertain etiology. VA medical records in 1994 reflect complaints of swelling of the hands (and feet) due to Indocin/ hydrochlorothiazide. In view of the varied etiologies of her joint symptoms, the veteran should be scheduled for VA examination by an orthopedic specialist who will provide opinion as to the etiology of her joint pain. With respect to the increased rating claim, the Board notes that the veteran was seen in January 1998 complaining of epigastric crampy pain, frequent nausea, and diarrhea, which she attributed to her ulcer. The examiner noted that the abdominal pain was atypical for an ulcer and ordered further evaluation in February 1998. Records of such treatment are not present in the claims folder. The VA's statutory duty to assist the veteran includes the duty to obtain recent treatment records so that the evaluation of the disability will be a fully informed one. Accordingly, this case is REMANDED for the following: 1. The RO should obtain relevant copies of VA clinical documentation pertaining to veteran's treatment from February 1998 to present and associate them with the claims folder. 2. The veteran should be scheduled for VA examination by an orthopedic specialist for the purpose of determining the nature and etiology of her joint pain. At the outset of the examination, she should specify the joints she believes have become symptomatic as a result of undiagnosed illness. After obtaining a complete history from her, reviewing the claims file and examining the veteran, the examiner should answer the following questions with respect to the joints at issue: (1) Is it at least as likely as not that the joint symptomatology is the result of undiagnosed illness; (2) Is it at least as likely as not that the joint symptomatology is the result of other chronic disability, and, if so, what is the diagnosis? The rationale for the opinion should be set forth. Following completion of this action, the RO should review the claim. Thereafter, in accordance with the current appellate procedures, the case should be returned to the Board for completion of appellate review. The Board intimates no opinion as to the ultimate outcome of this case. The veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. NANCY I. PHILLIPS Member, Board of Veterans' Appeals