Citation Nr: 0007357 Decision Date: 03/20/00 Archive Date: 03/23/00 DOCKET NO. 96-10 701 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a cervical spine injury with degenerative changes (cervical spine disorder). 2. Entitlement to service connection for a thoracic spine injury with degenerative changes (thoracic spine disorder). 3. Entitlement to service connection for a disorder of the shoulders. 4. Entitlement to an increased evaluation for the veteran's service-connected chronic lumbosacral strain with myalgia and degenerative joint disease, (chronic lumbosacral strain), currently evaluated as 40 percent disabling. 5. Entitlement to a total disability rating due to individual unemployability (TDIU) due to service-connected disability. REPRESENTATION Appellant represented by: Kenneth M. Carpenter, Attorney ATTORNEY FOR THE BOARD B. Lemoine, Counsel INTRODUCTION The veteran had active military service from October 1971 to May 1976. The Board of Veterans' Appeals (Board) received this case on appeal from a January 1996 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied the veteran's claim seeking entitlement to TDIU. That claim has been twice previously before the Board, in May 1997 and again in July 1998, and was twice remanded to the RO for additional evidentiary development. Following the Board's latest directives on Remand, the RO has continued the denial of the claim. The veteran has continued his appeal, and the claim is now returned to the Board. During the development of the TDIU issue, the veteran raised new claims seeking service connection for a cervical spine disorder, a thoracic spine disorder, and a disorder of the shoulders, as well as an increased evaluation for his service connected chronic lumbosacral strain. Those claims, amongst others, were all denied by a January 1999 rating decision. The veteran submitted a notice of disagreement pertaining to those issues in February 1999. In May 1999, he was provided with a statement of the case. His substantive appeal was also received in May 1999. Accordingly, those issues are now before the Board on appeal. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The veteran contends that he suffered an injury to both the cervical spine and thoracic spine in service; however, he was not treated for either disorder until many years after his service, and there is no competent evidence of record of any residual cervical spine disorder or thoracic spine disorder as a result of the veteran's service. 3. Although the veteran is currently diagnosed with an intermittently symptomatic neck and thoracic spine with degenerative changes on X-ray, as found by July 1997 VA examination, there is no competent evidence of record of a nexus between either currently diagnosed disorder and the veteran's service or any incident therein. 4. Although the veteran was diagnosed with shoulder stiffness on separation examination from service, there is no competent evidence of record of a current diagnosis of a disorder of the shoulders, other than subjective symptomatic complaints unsupported by objective findings. 5. The veteran has not submitted evidence sufficient to justify a belief by a fair and impartial individual that his claims of service connection for a cervical spine disorder, a thoracic spine disorder, or a disorder of the shoulders, are plausible. 6. The veteran's chronic lumbosacral strain is manifested by pain on motion, limitation of motion, spasm of the right paravertebral muscle, and tenderness over the lumbar area. However, there are no neurologic residuals, as the veteran has normal muscle mass, strength, and sensory functioning in all extremities; and his service-connected chronic lumbosacral strain is not productive of disc involvement, nor is the veteran's spine ankylosed, and most recent examination described his symptomatology as moderate in degree. 7. The veteran's service-connected disabilities include his chronic lumbosacral strain, evaluated as 40 percent disabling, and his hemorrhoids and conjunctivitis of the left eye, each evaluated as noncompensable, for a combined evaluation of 40 percent. 8. The veteran has reported that he has a high school education, that he left his employment in 1991, that he was previously employed in various construction trades as a carpenter and plumber, and prior to that as a postal clerk. He has reported being unable to work due to a variety of symptomatic complaints, to include back pain, but primarily because of complaints of severe pain and numbness in the legs and hands, frequent falling which has caused numerous other injuries, and the inability to walk without a cane. 9. The veteran has attributed his numerous neurologic and other symptomatic complaints to his service connected chronic lumbosacral strain; however, the medical record indicates that such neurologic and other symptomatic complaints are unrelated to his service connected chronic lumbosacral strain, as the medical record indicates all neurologic findings in all extremities are normal, many of the veteran's subjective complaints are unsupported by objective findings, and many of the complaints supported by objective findings are not related to his service-connected disorders. 10. The veteran's service-connected disabilities do not preclude all forms of substantially gainful employment, which are consistent with his educational background and occupational experience. CONCLUSIONS OF LAW 1. The veteran has not submitted well-grounded claims for service connection for a cervical spine disorder, thoracic spine disorder, or disorder of the shoulders. 38 U.S.C.A. § 5107(a) (West 1991). 2. The criteria for an evaluation in excess of 40 percent for the veteran's service connected chronic lumbosacral strain are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5295 (1999). 3. The criteria for a total disability rating based on individual unemployability due to service-connected disabilities are not met. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19, 4.25, 4.26 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background A careful review of service medical records reveals a normal entrance examination in October 1971. The veteran's service medical records show that in March 1973, while working on a golf course, he was struck by a golf cart. A line of duty determination reported that the veteran was making out a service order on the golf cart when an occupant turned on the key, causing the cart to jump forward and strike him. In March 1973, there was a service medical record notation of low back strain. The left trapezius and lumbosacral muscles were reportedly tender. There was no radiation of pain. The veteran was placed on limited duty with bed rest. In April 1973 the veteran was reportedly much improved, examination of the back was negative and he was instructed to return to normal activities. All subsequent treatment records between the date of the accident and his separation examination are devoid of complaints or treatment of low back pain. A review of other service medical records indicates the veteran was treated for conjunctivitis in April 1973, October 1974 and for eye irritation in February 1976. The veteran's separation examination report dated in April 1976 reflects that the veteran then had a normal spine, with full range of motion, as reported on the clinical evaluation portion of that report, but subjectively, recurrent low back pain was reported by the veteran since the March 1973 accident. He also reported mild pain manifested by stiffness of the shoulders bilaterally. The separation examination also noted the presence of hemorrhoids. The veteran's original claim seeking service connection was filed in June 1976. Post-service medical evidence includes a July 1976 VA examination report, which reflects that the veteran then had complaints of on-going back pain. An X-ray report from that examination showed that the veteran had a normal thoracolumbar spine, and that the veteran had a back disorder by history. Musculoskeletal findings indicated full range of motion of the shoulders, with some tenderness to palpation of the medial to right scapula, and some crepitus in the right shoulder. Range of motion of the back was 110 degrees forward, 30 degrees back, and 35 degrees laterally to both sides. All motor functions and sensory functions were intact. There was also a finding of conjunctivitis by history, although eyes were normal on examination, and small hemorrhoids were present. An August 1976 rating decision granted service connection for a low back strain, and awarded a 10 percent disability evaluation under Diagnostic Code 5295. Service connection was also granted for conjunctivitis and hemorrhoids, with noncompensable disability evaluations assigned to each disorder. The veteran next submitted a claim seeking an increased evaluation for his service connected low back strain in May 1990. Received in June 1990 were VA outpatient treatment records spanning from February to May 1990. These indicated that the veteran had a hyperextension injury to his left knee while playing football in February 1990. In April 1990, a therapy order sheet recorded that the veteran complained of left knee pain and also bilateral posterior shoulder pain. He gave a history of first hurting his knee in 1983 and hurting his back in 1973. Range of motion was reportedly normal with exception of knee and shoulders, which had full range of motion but could not be tested for strength due to complaints of pain and guarding. Another record in April 1990 noted that the veteran had canceled an appointment concerning his knee after reporting a severe increase in back pain. A May 1990 surgical record indicates the veteran underwent a left knee arthroscopy. The surgical record noted that the veteran had a history of low back pain for many years. The record also noted that he was currently an unemployed construction worker. The RO denied the veteran's claim seeking an increased evaluation in June 1990 and in November 1994, the veteran again claimed an increased evaluation. Received in January 1995 were VA outpatient treatment records spanning from January 1993 to January 1995. These records indicated ongoing intermittent treatment of the veteran for complaints of back, neck, and shoulder pain. In October 1994, the veteran reported that his back pain seemed to be getting worse and was greatest in the lumbar spine and in between the shoulder blades. The veteran also reported that his pain was not radiating into his legs but that he was experiencing some tingling and numbness going into the arms, bilaterally. On examination of the cervical spine, there was some tightness of the paravertebral muscles, but range of motion was full and strength was 5/5. Findings for the lumbar and thoracic spine reported very tight muscles, and range of motion markedly decreased with 3/5 strength. In December 1994, the veteran gave a history of having his head lodged between the wheel and front fender when being run over by a golf cart, and he reported injury to his back from his neck all the way to the bottom of the back. A January 1995 VA examination report noted that the veteran reported that he was injured by a three-wheeled vehicle during service, and that he did not have any post-service back injuries. The veteran then reported that he has had on- going low back pain with episodes of sharp back pain, occurring daily. The veteran denied bowel or bladder symptomatology, but did report sleeping problems as a result of pain. Notably, the veteran presented himself with a cane in the right hand, and walked slowly. Objectively, the veteran had a right paravertebral spasm when standing, and he did stand with a forward list. Tenderness over the lumbar area was noted with percussion with a hammer, although tenderness was not noted over the ilial lumbar area, over the sciatic notches, or over the trochanter. Flexion was described as 10 degrees at most, and lateral bending to the right and left was about five degrees, and rotation was also five degrees bilaterally. The veteran did not have paresthesia over the L3, L4, L5 and S1 dermatomes. Straight leg raising elicited low back pain at 45 degrees on the right, and straight leg raising at 70 degrees elicited pain on the left. All measurements of the thighs and calves were equal bilaterally. X-rays taken in conjunction with the VA examination revealed mild degenerative osteophytic spurring at the L3-L4 vertebral bodies. The impression was degenerative joint disease of the lumbar spine without radiculopathy, symptomatic. In November 1995, the veteran submitted his claim seeking TDIU, on which he reported working for the postal service from 1979 to 1986, and reported a series of construction jobs, as a carpenter or plumber, from 1986 through 1991. He had reportedly not worked full time since March 1991. He indicated that he had a high school education with no subsequent training. A similar affidavit from the veteran was submitted by his attorney in December 1995. On his affidavit, the veteran also stated that he regularly had experienced problems at work such as "difficulty in concentrating, performing tasks and completing tasks, difficulty with co-workers, difficulty with supervisors, explosive behavior, physical confrontation or violence on the job, flashbacks on the job, auditory hallucinations and homicidal feelings." (The Board notes that none of these complained of symptoms are shown to be in any way related to the veteran's service connected disorders.) The veteran also reported that he was required to see a doctor for outpatient treatment regularly and missed one week of work every three months. He reported leaving his most recent job because of back pain. On December 1995 VA examination, the veteran reported constant back pain, worsened by activity or movement, with brief periods of severe pain. The veteran also reported that he had fallen as a result of back pain. He stated this had happened 30 or 40 times and he was using a cane to prevent falling. The veteran denied bowel or bladder problems, and denied radiation of the pain into the legs, or tingling or numbness. The examiner described the veteran as an ill-kept male who walked into the office with a cane in his right hand. Flexion was 45 degrees, extension was 10 degrees, bilateral sideways tilt was 10 degrees, and bilateral rotation was 10 degrees. Paraspinous muscle spasm was present in the lumbosacral area, but notably, straight leg raising was negative bilaterally. There was good muscle strength, mass, and tone in the lower extremities. Sensation was intact in all modalities. The examiner diagnosed the veteran with severe chronic lumbosacral strain with pain and limitation of motion. In a February 1996 statement, the veteran reported that he was unable to work because of severe pain and numbness in his legs and hands. He reported using a cane to prevent falling and he reported that his frequent falls had resulted in other injuries, to include a knee injury that required an operation. The veteran also reported using marijuana and traveling to Mexico to obtain other medications to control his symptomatology, as he indicated more traditional medical treatment had been unsuccessful in treating his severe pain. The above evidence was considered by the Board in May 1997, when they denied the veteran's claim for an increased evaluation for his service connected low back strain, and remanded the TDIU claim. Subsequently, the veteran underwent a VA examination in July 1997. On examination, the veteran gave a history of an injury to his "whole" back in service with constant post- service back pain. He reportedly discontinued work 6 or 7 years earlier due primarily to back pain. He further reported an episode of "pinching" below the shoulder blades, in 1984, resulting in a fall and injury to the left knee with subsequent surgery. He claimed progressive pain in the cervical, thoracic, and lumbar spine since service. He denied any post-service back injury but did give a history of a 1982 motor vehicle accident with fracture of the right femur and dislocation of the right hip. He reported falling because of legs giving way and reported using a cane to prevent falling. The falling had reportedly caused injury to the shoulders, elbows, and left knee. He could reportedly walk 300-400 yards and sit two to three hours with back pain. There were no symptoms of radicular pain and no symptoms of neurological changes in any extremities. The examiner described the veteran as a well-nourished, well-developed male who appeared to be in good health, in no distress, who walked with a cane in the right hand, but with normal weight bearing and posture. On examination of the shoulders, both were normal with full range of motion, no expression of pain on motion, no palpable crepitus, and no tenderness on palpation. Examination of the spine noted normal spinal curvature throughout. He complained of tenderness to punch in the mid/low lumbar spine and over the low cervical spine. There was no other tenderness. There was no paravertebral muscle spasm or tenderness. There was full range of motion of the cervical spine without expression of pain, although the veteran reportedly had pain with any cervical motion. In the lumbar area, forward flexion was to 60 degrees with low back pain. Hyperextension was to 20 degrees, secondary to pain. There was full lateral flexion and rotational movement without pain. Straight leg raising was negative bilaterally. There were normal neurological findings in all extremities, with no deficits, normal muscle mass and strength. Pertinent impression was low back injury with chronic lumbosacral strain, symptomatic with limitation of motion; intermittently symptomatic neck with degenerative changes on X-ray; intermittently symptomatic thoracic spine with degenerative changes on X-ray; symptomatic shoulders without objective changes. The examiner further commented that there was no evidence within the claims file that the veteran was treated for a cervical or thoracic spine injury in service. It was also noted that although the veteran complained of chronic symptoms in the low back, there were no objective changes on examination and only mild degenerative changes on X-ray study. There was also no neurological loss, and normal muscle development and strength in the lower extremity, inconsistent with claims of intermittent falling due to back pain. The examining physician specifically opined that the veteran's symptoms in the neck, thoracic spine, shoulders, elbows, and left knee, were not etiologically related to his service connected low back disorder. The veteran underwent another VA examination in March 1998. At that time, the veteran complained of problems with both legs due to his low back pain. The veteran described increasing low back pain and episodes were it "pinches" so that he cannot move. The veteran did not describe radicular pain into the upper or lower extremities, although he claimed they intermittently "go to sleep". His chief complaint was of interscapular pain, although he reported pain throughout the spine. He also reported using a cane to prevent falling as he stated he sometimes fell when his back "pinches". He reported all physical activities were limited, he could walk with cane up to a mile but it would take 2.5 hours, and he could stand only 10-15 minutes, but denied any limitation of sitting. The examiner noted that although the veteran claimed to have injured his left knee due to a fall from back pain, the medical record clearly documented a left knee arthroscopy resulting from injury while playing football in 1990. The examination described the veteran as well- developed, well-nourished, in adequate health, and in no acute distress. He walked with a cane, but with normal weight bearing on lower extremities and normal gait. There was normal curvature throughout the spine. The veteran complained of pain even to light touch throughout the entire spine. There appeared to be some mild spasm of the left lumbar paravertebral muscle, although no actual muscle spasm was palpable. There was full cervical spine range of motion, although the veteran complained of neck pain with any motion. In the lumbar area, the veteran only forward flexed to 25 degrees because of pain, hyperextension to 10 degrees with pain, and showed lateral flexion and rotation to 20 degrees bilaterally, again complaining of pain with any motion. He pointed to the paravertebral and interscapular muscles as the location of most pain. There was no sciatic notch tenderness. Straight leg raising was negative bilaterally. There was no neurological deficit in any extremities, with muscle mass equal and normal. Motor strength was also normal in all extremities. Sensory modalities were intact throughout. The impression was of chronic lumbosacral strain, symptomatic with chronic myalgia and limitation of motion, functional loss secondary to pain, symptomatically moderate. The examiner also opined that as the veteran had no nerve root irritation, no radicular pain, and was neurologically normal in the lower extremities. He had no current disorder of the lower extremities related to the back. Prior knee surgeries were not shown to be related to the back, but instead to trauma to the knees. The veteran also underwent an examination of the eyes in March 1998, which noted that the veteran had some difficulty reading near objects but he denied any problems with his conjunctivitis and denied red eye. He underwent a VA examination of his hemorrhoids in November 1998, and he reported problems with hemorrhoids for the prior 20 years, with intermittent bleeding, more frequent recently, better with treatment with Preparation-H. He reported good sphincter tone and denied incontinence. On examination, there was no evidence of fecal leakage, good sphincter tone, and no apparent external bleeding. Grade II External hemorrhoids were seen, non-bleeding. There was no evidence of anemia, no anal fissure and no thrombosis. The diagnosis was that of Grade II hemorrhoids with recurrent bleeding. II. Analysis To summarize the contentions of the veteran's representative, it is argued that the veteran's entire back was injured in service when he was struck by a golf cart. It is argued that this caused not only the veteran's service connected chronic lumbosacral strain, but also his claimed cervical spine disorder, thoracic spine disorder, and disorder of the shoulders. In the alternative, it is argued that these claimed disorders are secondary to the service connected chronic lumbosacral strain. In support of these contentions, the representative points to the March 1973 service medical record which noted tenderness in the left trapezius and lumbosacral muscles, arguing that this documents an injury to the upper back and shoulders in service. The representative has cited to Mosby's Medical Dictionary, which defines trapezius as "A large flat triangular muscle of the shoulder and upper back." He also points to the service separation examination of the veteran, which noted bilateral shoulder stiffness. In conclusion, the representative argues that service connection is warranted as an in-service injury is shown, post-service continuity of symptomatology is shown, and a current diagnosis is shown. It is also contended that the veteran is entitled to an increased evaluation for his service connected chronic lumbosacral strain and also to TDIU, on an extra-schedular basis under 38 C.F.R. § 3.321 due to his inability to work since 1991. It is requested that if these claims are not granted, they should be referred to the Director of Compensation and Pension for consideration of an extra- schedular rating. Having summarized the pertinent contentions, the Board will now address each of the veteran's claims. a. Service Connection Claims Having discussed the pertinent evidence above, the Board notes that in order to establish service connection for a disability, there must be objective evidence that establishes that such disability either began in or was aggravated by service. 38 U.S.C.A. §§ 1110, 1131. If a disability is not shown to be chronic during service, service connection may nevertheless be granted when there is continuity of symptomatology post-service. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for a disease diagnosed after service discharge when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). Regulations also provide that service connection shall be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The threshold question regarding the veteran's appeal is whether he has presented well-grounded claims of service connection. A well-grounded claim requires more than an allegation; the claimant must submit supporting evidence. Furthermore, the evidence must justify a belief by a fair and impartial individual that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). In Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that, under 38 U.S.C. § 5107(a), the VA has a duty to assist only those claimants who have established well grounded (i.e., plausible) claims. More recently, the United States Court of Appeals for Veterans Claims (Court or CAVC) issued a decision holding that VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). Once a claimant has submitted evidence sufficient to justify a belief by a fair and impartial individual that a claim is well-grounded, the claimant's initial burden has been met, and VA is obligated under 38 U.S.C. § 5107(a) to assist the claimant in developing the facts pertinent to the claim. Accordingly, the threshold question that must be resolved in this appeal is whether the appellant has presented evidence that the claim is well grounded; that is, that the claim is plausible. In order for a claim to be well grounded, there must be (1) a medical diagnosis of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Epps, 126 F.3d at 1468; Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). Where the determinative issue involves medical causation or etiology, or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" or "possible" is required. Epps, 126 F.3d at 1468. Further, in determining whether a claim is well-grounded, the supporting evidence is presumed to be true and is not subject to weighing, except where the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). In regard to establishing a well-grounded claim, the second and third Epps and Caluza elements (incurrence and nexus evidence) can also be satisfied under 38 C.F.R. § 3.303(b) (1999) by (1) evidence that a condition was "noted" during service or during an applicable presumption period; (2) evidence showing post-service continuity of symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. Savage, 10 Vet. App. at 496. Moreover, a condition "noted during service" does not require any type of special or written documentation, such as being recorded in an examination report, either contemporaneous to service or otherwise, for purposes of showing that the condition was observed during service or during the presumption period. Id. at 496-97. However, medical evidence of noting is required to demonstrate a relationship between the present disability and the demonstrated continuity of symptomatology unless such a relationship is one as to which a lay person's observation is competent. Id. at 497. As explained below, the Board finds that the veteran has not presented well-grounded claims of service connection for a cervical spine disorder, thoracic spine disorder, or disorder of the shoulders. Having carefully considered all evidence of record, the Board initially notes that the veteran was injured in service when struck by a golf cart and subsequently did report lumbosacral tenderness, as well as tenderness in the left trapezius. The only diagnosis made at that time was of lumbosacral strain. There was no reported cervical or thoracic complaints or diagnosis in service. The veteran also reported bilateral shoulder stiffness on separation examination. The Board is satisfied that this medical evidence establishes an in- service injury to at least the veteran's left shoulder, and possibly to both shoulders. Although the veteran was never treated for cervical or thoracic complaint in service, he currently contends that the injury from the golf cart was not only to the low back, but the entire back, to include the cervical and thoracic spine. The Board will accept the validity of the veteran's contentions for purpose of determining well groundedness. See King. Accordingly, the Board finds that the veteran has satisfied at least one criterion of Caluza as to all his service connection claims, by presenting some credible evidence (both by service medical records and lay observations) of an in-service occurrence of injury to the shoulders, as well as the cervical and thoracic spine. Regarding the claimed cervical spine disorder and thoracic spine disorder, the Board also notes that VA examination in July 1997 diagnosed an intermittently symptomatic neck and thoracic spine with degenerative changes on X-ray study. This recent diagnosis satisfies a second requirement of Caluza for these two diagnoses, namely the medical diagnosis of a current disability. The Board notes, however, that the record does not establish a medical diagnosis of any current disability of the shoulders. In this regard, the Board notes that VA outpatient treatment records, as well as several VA examinations have recorded the veteran's symptomatic complaints of pain of the shoulders. However, on VA examination in July 1997, the diagnosis indicated symptomatic complaints of pain without objective changes. Specifically, the shoulders were normal on examination, with full range of motion, no pain on motion, and no palpable tenderness or crepitus. Likewise, on VA examination in March 1998, motor strength and sensory findings were normal in all extremities and there was no diagnosis pertaining to the shoulders. Accordingly, as there is no medical evidence of a current disorder pertaining to the shoulders, the Board finds this claim to be not well-grounded. In this regard, the Board has carefully considered the veteran's many documented complaints of pain in the shoulders, but notes that there are no objective findings to support his complaints. Furthermore, the Court has held that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, No. 97- 1948 (U.S. Vet. App. December 29, 1999). See also Rabideau v. Derwinski, 2 Vet. App. 141, 142-143 (1992) (Service connection may be granted for a chronic, not acute, disease or disability); and Brammer v. Derwinski, 3 Vet. App. 223 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such injury resulted in a present disability). Returning to the claimed cervical and thoracic disorders, two of the requirements of Caluza are satisfied but the third requirement remains, namely medical evidence of nexus. In this regard, the Board next notes that as part of his July 1976 VA examination, shortly after service, thoracolumbar X- ray study was negative and there were absolutely no complaints regarding the cervical or thoracic spine. Thus, at that time, the cervical and thoracic spine were normal. Likewise, medical records for many years after the veteran's service are negative for any complaints or treatment pertaining to the cervical or thoracic spine. The medical record demonstrates that the veteran was capable of playing football as late as 1990, prior to suffering a knee injury. It was not until the mid 1990s that VA outpatient treatment records indicate the veteran was complaining of neck and upper back pain. In sum, the Board notes that there is simply no competent evidence of a nexus between either the claimed cervical spine disorder or thoracic spine disorder and the veteran's active military service. To the contrary, the only evidence of record which discusses the question of nexus is the July 1997 VA examination, which opined that there was no evidence of treatment in service for a cervical or thoracic injury and that the veteran's neck, thoracic and shoulder symptoms were not etiologically related to the service connected chronic lumbosacral strain. In addition to the veteran having presented no competent evidence of nexus for his claimed cervical and thoracic disorders, the Board notes that by his own history he worked for years after service as both a postal clerk, and in the construction trades, as a carpenter and plumber, without seeking treatment for any cervical or thoracic pain. It can be assumed that such employment included strenuous physical activity, which the veteran apparently performed without submitting evidence of needing any post-service medical treatment until the 1990s. As the veteran's claims are not well-grounded, the Board need not evaluate this evidence further, but simply notes the presence of negative evidence pertaining to the claims. Although his work history and post-service medical history of injury from football and motor vehicle accidents raises the possibility that his post- service occupational or recreational activities may be responsible for his current complaints, the Board makes no such inference in the absence of medical opinion evidence. Nevertheless, as there is no competent evidence of record of a nexus between the veteran's service and his currently diagnosed cervical and thoracic disorders, the Board also finds these claims to be not well-grounded. As for the contentions of the veteran that his currently diagnosed cervical spine disorder and thoracic spine disorder are due to his service, there is simply no medical evidence to support such an argument. The Board has also considered the veteran's contentions of continued symptomatology after service. See Savage. However, even accepting the history of continued symptomatology as true for purposes of determining the well- groundedness of these claims (see King), there is still no competent medical evidence tending to demonstrate that the current disorders are possibly linked to service. Medical evidence noting the continuity of symptomatology is required in a case such as this. In summary, the Board has also considered the contentions of the veteran and, inasmuch as he is offering his own medical opinion and diagnosis, notes that the record does not indicate that he has any professional medical expertise. See Bostain v. West, 11 Vet. App. 124, 127 (1998) ("lay testimony . . . is not competent to establish, and therefore not probative of, a medical nexus"); Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998). See also Moray v. Brown, 5 Vet. App. 211 (1993); Grottveit v. Brown, 5 Vet. App. 91 (1993); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). As noted previously, the judicial precedent in Caluza requires, for a claim to be well grounded, competent evidence of a current disability (medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). The veteran has provided competent evidence, in the form of his contentions and service medical records, that he did experience some type of injury in service involving his shoulders, neck, and thoracic spine. He has also provided competent medical evidence that he is currently diagnosed with a cervical spine disorder and thoracic spine disorder. However, there is no such evidence of a current diagnosis for a disorder of the shoulders. Furthermore, there is no medical evidence that the veteran's currently diagnosed cervical and thoracic disorders are related to his service. As such evidence has not been presented here, the veteran has not submitted well-grounded claims and all his claims seeking service connection must be denied. b. Increased Evaluation Claim As a preliminary matter, the Board finds that the veteran's claim is "plausible" and, thus, well grounded within the meaning of 38 U.S.C.A. § 5107(a). A claim, as here, that a service-connected disability has become more severe is well grounded where the claimant asserts that a higher rating is justified due to an increase in severity of the condition. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 631-632 (1992). The Board is satisfied that all available relevant evidence has been obtained regarding the claim and that no further assistance to the veteran is required to comply with 38 U.S.C.A. § 5107(a). Disability evaluations are determined by comparing the symptoms the veteran is presently experiencing with criteria set forth in the VA's Schedule for Rating Disabilities-which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. When making determinations as to the appropriate rating to be assigned, VA must take into account the veteran's entire medical history and circumstances. See 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). However, where, as here, entitlement to compensation already has been established, and the appropriateness of the present rating is at issue, his current level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). If the disability at issue is of a musculoskeletal nature or origin, then VA may, in addition to applying the regular schedular criteria, consider granting a higher rating for functional impairment caused by pain, limited or excess movement, weakness, excess fatigability, or incoordination- assuming these factors are not already contemplated by the governing rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The veteran is currently service-connected for chronic lumbosacral strain, and has a 40 percent disability evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5295 (1999). Under Diagnostic Code 5295, a 40 percent disability rating is assigned where the condition is severe and is characterized by listing of the whole spine to the opposite side, positive Goldthwait's sign, marked limitation of forward bending in a standing position, a loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of the joint space, or some of the above with abnormal mobility on forced motion. However, as a 40 percent disability rating is the highest schedular rating under this diagnostic code, the veteran can only receive a higher schedular evaluation under another diagnostic code. Likewise, the veteran is also currently receiving the highest possible evaluation under Diagnostic Code 5292, based on limitation of motion of the lumbar spine (to include as a result of degenerative changes in the spine, pursuant to Diagnostic Code 5003). Under Diagnostic Code 5292, a 40 percent disability rating, the highest assignable, is assigned for severe limitation of motion. The veteran's limitation of motion has been evaluated as severe, so no higher evaluation is available under this Diagnostic Code. The Board acknowledges that the veteran experiences pain and tenderness along lumbar spine. However, even if functional loss due to such symptoms are considered, the evidence does not demonstrate ankylosis or disability comparable to unfavorable ankylosis, the basis for a 50 percent rating under Diagnostic Code 5289. The veteran and his representative have also argued that the neurological manifestations of the veteran's service- connected chronic low back strain warrant the assignment of a higher disability rating under Diagnostic Code 5293, which pertains to the rating of intervertebral disc syndrome. Under this code, a 60 percent disability rating is assignable where the syndrome is pronounced, and is characterized by persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief. A 40 percent disability rating is assignable where the syndrome is severe, and is characterized by recurring attacks with intermittent relief. However, the Board notes that all neurological findings pertaining to all the veteran's extremities have been essentially normal on both July 1997 and March 1998 VA examinations. Those examinations showed no neurological residuals. As such, an increased evaluation under Diagnostic Code 5293 is not demonstrated by the record. The Board further notes that the veteran's claim for an increased evaluation was previously denied by the Board in May 1997. Since that time, there is no evidence of the veteran requiring any additional medical treatment for his service connected disorder. The only new evidence are the contentions of the veteran and his representative and the VA examinations performed in July 1997 and March 1998. If anything, those examinations indicate that the veteran's overall physical condition has improved since the Board's May 1997 decision. There is certainly no medical evidence of the disorder having worsened. The 1997 examination described the veteran as appearing to be well-nourished, well developed, in good health, in no distress, and walking with a cane but with normal weight-bearing and posture. Observations in the March 1998 examination were essentially similar. Although the veteran had significant complaints of pain and there was showing of tenderness in the lumbar spine, along with continued limitation of motion on both examinations, there was also indication of normal curvature throughout the spine and minimal degenerative changes. The March 1998 VA examination diagnosed the veteran's chronic lumbosacral strain as symptomatically moderate in degree. For the foregoing reasons, the Board finds that a schedular increase in the assigned evaluation for chronic lumbosacral strain is not warranted under any of the aforementioned diagnostic codes. The Board also finds no showing that the veteran's chronic lumbosacral strain reflects so exceptional or unusual a disability picture as to warrant the assignment of an increased evaluation on an extra-schedular basis. In this regard, the Board notes that the chronic low back strain is not shown to significantly impact his employment (beyond that which is contemplated in the rating assigned). Such problems are not shown to warrant frequent periods of hospitalization or to otherwise render impractical the application of the regular schedular standards. Indeed, the vast majority of the veteran's complaints and treatments appear to have been more for his nonservice-connected knee injuries, neurological complaints, and cervical, thoracic and shoulder disabilities. In the absence of evidence of such factors, the Board is not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 157, 158-59 (1996); Floyd v. Brown, 9 Vet. App. 88, 98 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). c. TDIU Claim As noted immediately above, the veteran has numerous disorders and complaints which are nonservice-connected, to include complained of disorders of both knees, both elbows, neurologic disorders of the upper and lower extremities, as well as a cervical spine disorder, a thoracic spine disorder, and claimed disorder of the shoulders. However, none of these disorders are pertinent to the veteran's claimed TDIU as only service connected disorders may be considered for this purpose. In this regard, the Board notes that the veteran has three service connected disorders, chronic lumbosacral strain, and his hemorrhoids and conjunctivitis. The chronic lumbosacral strain is evaluated as 40 percent disabling and has been thoroughly discussed immediately above and need not be discussed further here. The veteran's conjunctivitis is noncompensably disabling and the veteran has made no contentions or arguments that this disorder has worsened or in any way contributed to his claimed unemployability. This is likewise true of the veteran's service connected hemorrhoids which are also noncompensably disabling. Recent VA examination in November 1998 did indicate the presence of non-bleeding Grade II external hemorrhoids. Such would not warrant an increased (compensable) evaluation under Diagnostic Code 7336, as hemorrhoids are noncompensable if mild or moderate in degree. A 10 percent disability evaluation is warranted for large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue and evidencing frequent recurrences. No such level of disability has been contended by the veteran. Generally, total disability will be considered to exist when there is present any impairment of mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. See 38 C.F.R. § 3.340. Total disability ratings are authorized for any disability or combination of disabilities for which the Schedule for Rating Disabilities prescribes a 100 disability evaluation or, with less disability, if certain criteria are met. Id. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. For the above purpose of one 60 percent disability, or one 40 percent disability in combination, disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, will be considered as one disability. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. See 38 C.F.R. § 4.16(b). If the schedular rating is less than 100 percent, the issue of unemployability must be determined without regard to the advancing age of the veteran. See 38 C.F.R. §§ 3.341(a), 4.19. Marginal employment shall not be considered substantially gainful employment. See 38 C.F.R. § 4.16(a). Factors to be considered are the veteran's education, employment history, and vocational attainment. See Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). In reaching such a determination, the central inquiry is "whether the veteran's service connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993) (emphasis added). Consideration may not be given to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. While neither the United States Code nor the Code of Federal Regulations offers a definition of "substantially gainful employment," VA Adjudication Procedure Manual, M21-1, Part VI, para. 7.09(a)(7) defines that term as "that which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." As previously noted the veteran has only one service connected disability evaluated as 40 percent disabling, with two additional service connected disabilities evaluated as noncompensably disabling. Accordingly, his combined disability evaluation is 40 percent. Clearly, such disability is not one which, by regulation, is sufficient to render the average person unemployable, nor is it a single disability evaluated as 100 percent disabling. Moreover, although the veteran has a single disability evaluated as 40 percent disabling, his combined disability evaluation is not at least 40 percent disabling; hence, he does not meet the percentage requirements under 38 C.F.R. § 4.16(a). As such, the veteran may be granted a total rating only if the criteria for consideration of a total rating on an extra- schedular basis, pursuant to 38 C.F.R. § 4.16(b), are met. In this regard, on his application for a total rating, the veteran reported that he had a high school education. His employment history includes work in the construction trades, as a carpenter and plumber, until 1991. He claims he last worked full time in 1991 because he became too disabled to continue working. The basis for being unable to work was initially reported as a number of stress related issues, and subsequently reported as due to neurologic problems with all extremities, and finally as due to increasing back pain. The Board has considered all of the veteran's contentions in this regard, but as previously discussed with the veteran's increased evaluation claim, all neurologic findings pertaining to the veteran have been essentially normal and many of the veteran's complaints have been either unsupported by objective findings or related to non-service connected disorders. The Board does not question that the veteran experiences pain due to his service connected chronic lumbosacral strain. However, such pain is adequately compensated by the veteran's current 40 percent disability evaluation for that disorder. This is particularly true when it is noted that most recent VA examination described the veteran's chronic lumbosacral strain symptoms as only moderate in degree and further described the veteran as essentially in good health. The Board also notes that the veteran was reported to be an unemployed construction worker as early as February 1990 in VA outpatient treatment records. Those same records clearly noted that the veteran had injured his knee while playing football and subsequently underwent an arthroscopy for the injury. Thus, the evidence clearly indicates that the veteran was unemployed prior to any worsening of his service connected chronic lumbosacral strain. It cannot be credibly argued that the veteran was physically incapable of employment at that time, as he was obviously capable of playing football which is a strenuous activity. There is no doubt that the veteran's current chronic lumbosacral strain causes pain which impacts the veteran's ability to perform manual labor that would be required in the construction trade. However, the Board notes that the veteran also has prior clerical experience, such as his position during service managing golf equipment, or his subsequent position as a postal clerk. There is no indication of record that the veteran is unable to perform such clerical employment. Furthermore, fairly significant interference with the veteran's employability is contemplated in his current 40 percent evaluation. The evidence in this case simply does not demonstrate that he is unable to obtain or retain substantially gainful employment as a result of his service connected disabilities. The information of record does not objectively support the veteran's assertion that he is unemployable due to his service-connected disability. Significantly, there is no opinion by a medical or other professional that the veteran's service-connected disabilities have rendered him unemployable, and he has not indicated that any such opinion is in existence. In conclusion, the evidence simply does not indicate, considering the veteran's high school education and years of employment history, that his service-connected disabilities would preclude all forms of employment "ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." In view of the foregoing, the Board finds that the record presents no basis for allowance of the claim. While the Board has considered the applicability of the doctrine of reasonable doubt under 38 U.S.C.A. § 5107(b), the preponderance of the evidence is against the veteran's claim and that doctrine is inapplicable. III. Conclusion The Board is satisfied that the RO took all reasonable steps to properly develop the record. The RO has made every reasonable effort to obtain all pertinent treatment records identified by the veteran. In this regard, the Board notes that the veteran has given a history of having injured his left knee originally in 1983, prior to the 1990 arthroscopy, and he has also reported being involved in a motor vehicle accident in 1982, resulting in a fracture of the right femur and dislocation of the right hip. The Board notes that these treatment records are not within the claims file. However, the Board further notes that these treatment records involve nonservice-connected disorders for which the veteran is not currently seeking service connection. Therefore, these records do not appear pertinent to the claims currently before the Board. The Board further notes that this case has been twice previously remanded, the veteran has been furnished numerous VA examinations pursuant to these prior remands, and under the circumstances, a further remand would only unnecessarily delay the resolution of the veteran's appeal. The veteran has not informed VA of the existence of any available evidence that would render his service connected claims well grounded. Nor has he contended that any further relevant post-service records exist, pertinent to his service connection, increased evaluation, or TDIU claims. Hence, the Board concludes that there are no additional pertinent records of treatment which are not in the claims folder and would be available. See McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Counts v. Brown, 6 Vet. App. 473, 477 (1994). The Board therefore finds that no further action is warranted relative to the development of the appellant's claims, based upon the information currently of record. Consequently, a remand for additional evidentiary development is not warranted under the facts of this case. ORDER Service connection for a cervical spine disorder, thoracic spine disorder, and disorder of the shoulders is denied, since well-grounded claims have not been presented. An increased evaluation for the veteran's service connected chronic lumbosacral strain, greater than the currently assigned 40 percent disability evaluation, is denied. A total rating based on individual unemployability due to service-connected disabilities is denied. JACQUELINE E. MONROE Member, Board of Veterans' Appeals