Citation Nr: 0003189 Decision Date: 02/08/00 Archive Date: 02/15/00 DOCKET NO. 94-30 365 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for amblyopia of the left eye. 2. Entitlement to service connection for headaches. 3. Entitlement to an initial disability evaluation in excess of 10 percent for residuals, fracture of the left humerus. 4. Entitlement to an initial disability evaluation in excess of 10 percent for arthritis of the knees and the hands. REPRESENTATION Appellant represented by: New York Division of Veterans' Affairs WITNESSES AT HEARINGS ON APPEAL Appellant and his spouse INTRODUCTION The veteran has reported active service from August 1970 to August 1990. The veteran brought a timely appeal to the Board of Veterans' Appeals (the Board) initially from a 1990 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York. The Board in September 1996 remanded the case after receiving the veteran's request for a Board hearing. The veteran was present at a Board hearing in November 1997. The Board in January 1998 remanded the issues of entitlement to service connection for amblyopia and headaches and entitlement to increased ratings for the disabilities of the left shoulder, the hands and the knees. The case has recently been returned to the Board for appellate consideration. FINDINGS OF FACT 1. The claim of entitlement to service connection for amblyopia of the left eye is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 2. The claim of entitlement to service connection for chronic headaches is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 3. The veteran's left hand disability from arthritis is principally manifested by persistent decrease in strength and grip and increased effort that combined produce appreciable impairment; not shown is evidence of overt weakness, excess fatigability or incoordination or atrophy. 4. The veteran's right hand disability from arthritis is principally manifested by persistent decrease in strength and grip and increased effort that combined produce appreciable impairment; no currently shown is evidence of overt weakness, excess fatigability or incoordination or atrophy. 5. The veteran's left knee disability is principally manifested by persistent knee pain with motion, appreciable crepitus and limited strength without demonstrable limitation of motion or instability currently shown; there is no evidence of overt incoordination, excess fatigability, weakness or atrophy. 6. The veteran's right knee disability is principally manifested by persistent knee pain with motion, appreciable crepitus and limited strength without demonstrable limitation of motion or instability currently shown; not shown is evidence of overt weakness, incoordination, excess fatigability, or atrophy. 7. Residuals of the left humerus fracture are principally limitation of motion to shoulder level and pain that result impairment from exacerbations of pain and may interfere with work, but without current evidence of overt weakness, incoordination, excess fatigability, or atrophy. 8. The veteran's disabilities of the knees, the hands and the left shoulder have not rendered his disability picture unusual or exceptional in nature, markedly interfered with employment, or required frequent inpatient care as to render impractical the application of regular schedular standards. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for amblyopia of the left eye is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 2. The claim of entitlement to service connection for headaches is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 3. The criteria for an initial disability rating 10 percent for arthritis of the left knee have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003 5260, 5261 (1999). 4. The criteria for an initial disability rating of 10 percent for arthritis of the right knee have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003 5260, 5261 (1999). 5. The criteria for an initial disability rating of 20 percent for residuals of a fracture of the left humerus have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.40, 4.45, 4.59, 4.69, 4.71a, Diagnostic Codes 5201, 5203 (1999). 6. The criteria for an initial disability rating 10 percent for arthritis of the left hand have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003 (1999). 7. The criteria for an initial disability rating of 10 percent for arthritis of the right hand have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Service connection for amblyopia of the left eye and headaches. Factual Background The veteran's service medical records show a frontal head injury sustained in a May 1973 automobile accident. An X-ray was read as negative and the impression was skull contusion. A clinical record entry dated in November 1973 notes skull sutures removed. It was reported in July 1975 that he was kicked behind right ear by prisoner in jeep but had no pain at the area or headache. An examination in October 1982 showed he was normal neurologically and that he had 20/25 distant vision. In April 1980 it was reported that he did not wear glasses but mentioned poor judgment of distance and bad night visual acuity. It was reported that he had been struck in the left eye at age 5 or 6 and told then he would probably have blurred visual acuity. The examination found 20/40 left eye visual acuity. The diagnosis was amblyopia of the left eye. On an August 1987 examination the veteran was found to be normal neurologically, and left eye visual acuity was 20/30 with refraction. There was no history of headache or eye trouble. An August 1987 upon referral from the reception station reports that he never wore glasses and had been told he had a lazy eye. It was noted he had been hit in the left eye at age 5 and did not have diplopia. He complained of depth perception errors. The assessment was constant left exotropia and hyperopia with hyperopic astigmatism of the right eye and no refraction at present. The medical examination in May 1990 for separation from service showed a normal neurological evaluation, left eye lag and 20/25 near and distant visual acuity in the left eye. The veteran reported a history of frequent or severe headaches and eye trouble. The examiner's elaboration mentioned headaches with increased stress that were preceded by nausea and lightheadedness and relieved with 20 minutes of rest. Lazy eye on the left side was also mentioned. An eye evaluation in July 1990 found slight hyperopia of both eyes, left eye amblyopia and exotropia and binocular visual acuity 20/20. He complained of lazy left eye on the initial VA examination in late 1990 and on further examination in August 1991 he reported some difficulty seeing out of the left eye for 10 years and gave a history of left eye trauma as a child. His left eye visual acuity was 20/30 and the examiner mentioned a faint "RPE" irregularity in the left eye. The impression was decreased visual acuity in the left eye on the basis of retinal pathology manifested by surface and "RFE" irregularities. The examiner opined that the etiology cannot be determined but if not present earlier could represent central serious chorioretinopathy. The examiner stated that exotropia with no diplopia cannot substantiate claim of no eye deviation as child. The examiner opined that possible exophoria which decompensated with poor visual acuity in the left eye into exotropia was somewhat speculative since previous evidence of visual acuities would be required. The examiner also reported mild refractive error of the left eye. Guthrie Clinic records dated in January 1992 report headaches for two or three years, left side increase in past year with normal imaging study. There was also reference to headache type unknown. An August 1992 record entry noted complaint that medication had caused headache and nausea. A VA examiner for hypertension in December 1992 noted the veteran's headache complaints and doubted a relationship to blood pressure. It was reported that the veteran believed headaches were related to stress or anxiety. The physician opined that the headache history was quite possibly not related to blood pressure at all but may be a migraine type syndrome. On a VA examination in May 1993 the veteran reported a headache history of about two a month for which treatment had included injection for severe generalized headache. The examiner opined that the veteran appeared to have a mild case of migraine. Guthrie Clinic records show in February 1995 that the veteran was concerned that headaches were associated with his hypertension. The assessment was hypertension uncontrolled by medication and chronic headaches. In was reported on a VA eye examination in September 1998 that the veteran had long standing left eye ambylopia secondary to a left exotropia. The report noted no injury or surgery to either eye. His corrected visual acuity in the left eye was 20/30 and he had constant left exotropia. Slit lamp examination showed clear cornea, anterior chamber, iris and lens. The impression was left exotropia with amblyopia long-standing since childhood. The examiner stated that this condition was not service-connected. The examiner indicated that the veteran's claims file and the Board remand had been reviewed. A VA neurology examination in September 1998 shows the examiner stated that the veteran's claims file and the Board remand had been reviewed. The report noted the veteran's present employment and past medical history of headaches and joint pain. Headaches were reported since the early 1980's and described as frontal, usually early morning and occurring approximately three times a month. Blurred vision and nausea accompanied the headaches. The veteran stated that he would take extra-strength Excedrin and lay down in a quiet dark room for about a half-hour. He reported that about once in six months he had a headache that lasts most of the day and that he was absent from work two or three days a year because of headaches. The assessment was headaches of unknown etiology. The examiner stated that the probable etiology of headaches cannot be determined nor could the nature of the headaches. Criteria Service connection may be granted for a disability resulting from personal injury or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 1991). Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. Each disabling condition shown by a veteran's service records, or for which he seeks a service connection must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence. Determinations as to service connection will be based on review of the entire evidence of record, with due consideration to the policy of the Department of Veterans Affairs to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 C.F.R. § 3.303(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Congenital or developmental defects, refractive error of the eye, personality disorders and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303(c). A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. (1) The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will not be considered service connected unless the disease or injury is otherwise aggravated by service. (2) Due regard will be given the places, types, and circumstances of service and particular consideration will be accorded combat duty and other hardships of service. The development of symptomatic manifestations of a preexisting disease or injury during or proximately following action with the enemy or following a status as a prisoner of war will establish aggravation of a disability. 38 C.F.R. § 3.306. A threshold question to be answered is whether the veteran has presented evidence of a well grounded claim; that is, a claim that is plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Although the claim need not be conclusive, it must be accompanied by supporting evidence. An allegation alone is not sufficient. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Three discrete types of evidence must be present in order for a veteran's claim for benefits to be well grounded: (1) There must be evidence of a current disability, usually shown by a medical diagnosis. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); (2) There must also be competent evidence of incurrence or aggravation of a disease or injury in service. This element may be shown by lay or medical evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991); and (3) There must be competent evidence of a nexus between the in-service injury or disease and the current disability. Such a nexus must be shown by medical evidence. Lathan v. Brown, 7 Vet. App. 359, 365 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In determining whether a claim is well grounded, the Board is required to presume the truthfulness of the evidence. Robinette v. Brown, 8 Vet. App. 69, 77-8 (1995); King v. Brown, 5 Vet. App. 19, 21 (1993). In order for a claim to be well grounded, there must be (1) competent evidence of a current disability (a medical diagnosis); (2) incurrence or aggravation of a disease or injury in service (lay or medical evidence); and (3) a nexus between the in-service disease or injury and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Analysis Section 5107 of title 38, United States Code unequivocally places an initial burden upon the claimant to produce evidence that his claim is well grounded; that is, that his claim is plausible. Grivois v. Brown, 6 Vet. App. 136, 139 (1994); Grottveit v. Brown, 5 Vet. App. 91, 92 (1993). Because the veteran has failed to meet this burden, the Board finds that his claims for service connection for left eye amblyopia and chronic headaches are not well grounded and must be denied. The Board in January 1998 did discuss whether the claim of entitlement to service connection for headaches was well grounded. However, the Board must apply the current legal standard that requires a well grounded claim before there is any duty to assist the appellant in the development of facts pertinent to the claim. Morton v. West, 12 Vet. App. 477 (1999). Where the determinative issue involves causation or a medical diagnosis, competent medical evidence to the effect that the claim is possible or plausible is required. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The claimant does not meet this burden by merely presenting his lay opinion because he is not a medical health care professional and does not constitute competent medical authority. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Consequently, his lay assertions cannot constitute cognizable evidence, and as cognizable evidence is necessary for a well grounded claim, Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992), the absence of cognizable evidence renders a veteran's claim not well grounded. Turning to the veteran's claims for service connection for left eye amblyopia and headaches, the evidence reviewed initially by the RO did show headache complaints on the separation examination by history but normal neurological status and no diagnosis of a chronic headache disorder. Since service there have been reports of headaches that have not been linked to the veteran's hypertension. One examiner believed that the veteran might have a migraine disorder but did not link it to service. The recent examination did not link a chronic headache disorder to service. In summary, no evidence, either through medical records or medical opinion has offered a basis for a favorable determination with respect to a chronic headache disorder and none has been offered or brought to the Board's attention. Concerning amblyopia, the Board does recognize the service medical records on occasion mention this and refractive error of the left eye, but thereafter, the competent evidence does not offer a nexus to service for amblyopia of the left eye. The Board would point out that a refractive error, as provided by regulation, is not a disability under the law. The amblyopia was found to represent a long-standing disorder linked to childhood on recent VA examination. There is the veteran's history of left eye trauma as a child and no basis to link the inception of amblyopia to any incident of service. In summary, the medical evidence of record does not offer a nexus to service. As it is the province of trained health care professionals to enter conclusions that require medical opinions as to causation, Grivois, the veteran's lay opinion is an insufficient basis upon which to find his claims well grounded. Espiritu. Accordingly, as a well grounded claim must be supported by evidence, not merely allegations, Tirpak, the veteran's claims for service connection for chronic headaches and amblyopia of the left eye must be denied as not well grounded. Although the Board considered and denied the appellant's claims on a ground different from that of the RO, which denied the claim on the merits, the veteran has not been prejudiced by the decision. This is because in assuming that the claims were well grounded, the RO accorded the appellant greater consideration than his claims in fact warranted under the circumstances. Bernard v. Brown, 4 Vet. App. 384 (1993). In light of the implausibility of the appellant's claims and the failure to meet his initial burden in the adjudication process, the Board concludes that he has not been prejudiced by the decision to deny his appeal for service connection as not well grounded. The Board further finds that the RO through the statement of the case and supplemental statements of the case has advised the appellant of the evidence necessary to establish a well grounded claim, and he has not indicated the existence of any post service medical evidence that has not already been obtained that would well ground his claims. McKnight v. Gober, 131 F.3d 1483 (Fed.Cir. 1997); Epps v. Gober, 126 F.3d 1464 (Fed.Cir. 1997). II. Evaluation of the left humerus, arthritis of the knees and the hands. Factual Background The veteran's service medical records show pertinently a humeral head fracture and dislocation of the left shoulder in 1983 with follow up though the year. In April 1989 bilateral patellar tendinitis is mentioned. In January 1990 severe joint pain in the fingers and knees is reported with knee X- rays reported as showing spurs of the patellae and left tibial plateau. In February 1990 he reported knee pain complaints and a profile was issued recommending that he run at his own pace and distance. Another profile in March 1990 for degenerative joint disease of the knees provided for no running. The May 1990 separation examination shows a diagnosis of degenerative joint disease of the knees and a clinical evaluation that found normal lower and upper extremities. The history of arthritis and joint deformity referred to the knees and left shoulder. It was noted on the examination form that he was left-handed. The designation of left handedness was also made on an August 1987 physical examination. On a VA general medical examination in late 1990 the veteran complained of painful knees and being unable to raise the left shoulder completely. He provided a history of fracture and dislocation of the shoulder and stiffness and discomfort in hands and knees. An examination found no effusion of the hands, good range of motion without tenderness and shoulder motion generally reasonable with good muscle bulk. The examiner reported quite audible crepitus on range of motion of knees greater on right and without pain. An orthopedic examiner reported the veteran's complaint of posterior aspect left shoulder pain particularly when using the arms above shoulder level. The veteran was reported as being right-handed. He also complained of hand and knee pain. The examiner found the left shoulder stable, with normal contour and no tenderness. There was a full range of motion of the left arm at the shoulder with forced elevation movements causing pain along the posterior aspect. An X-ray was read as showing old traumatic deformity. The examiner found no loss of movement or strength of the hands and no obvious evidence of an arthritis condition of small joints. The veteran made and opened completely a strong fist in both hands. As for the knees, the examiner reported no swelling or evidence of bursitis and no effusion. The range of motion was from 0 to 130 degrees. There was no pain or localized tenderness and the knees were stable with no laxity and negative McMurray's. The diagnoses were postoperative residuals, healed fracture/dislocation of the left shoulder and bilateral hand and knee joint pain with X- ray findings of early patellofemoral arthritis and post- traumatic deposit at the base of the left fifth metacarpal. The RO in November 1990 granted service connection for residuals, fracture/dislocation of the left humerus (minor) and rated it noncompensable under Diagnostic Code 5202 criteria. Bilateral patellofemoral joint spurring was also rated noncompensable under Diagnostic Code 5003 criteria, both from September 1990. R.S., M.D., in January 1991 obtained knee X-rays showing medial joint space narrowing and infrapatellar spurring of both knees. VA outpatient reports coinciding with the radiology record note complaints of bilateral knee pain and left shoulder pain. A VA record dated in February 1992 reported that X-rays had confirmed degenerative joint disease in the knees with joint space loss. Gutherie Clinic reports in 1992 and 1993 mention degenerative changes of the proximal interphalangeal joints of the index, fourth and fifth fingers of both hands and the left fifth proximal interphalangeal joint and distal interphalangeal joint. Also mentioned are full range of motion and diagnosis of joint stiffness, pain and swelling and degenerative joint disease by X-ray. Clinic records dated in late 1993 mention knee crepitus and knee pain complaints. On VA examination in May 1993, the veteran complained of hand numbness and swelling. Noted was difficulty with the small joints probably related to arthritis with the possibility of later developing carpal tunnel syndrome. On VA examination in October 1993 he complained of pain and limitation of motion in the left shoulder and reportedly said he was left- handed. The examiner found all deep tendon reflexes hyperactive and no external evidence of knee arthritis. The veteran complained of pain with deep knee bending. Examination of the interphalangeal joints of the fingers disclosed no stigmata of arthritis. He showed very definite limitation of motion of the left shoulder, as he could not hyperabduct more than 10 degrees above horizontal. Internal and external rotation was about 25 percent less than normal function. The examiner stated that the veteran was very apprehensive with definite limitation of motion of the left shoulder. The RO in October 1993 rated degenerative arthritis of the knees and hands, X-ray evidence only, 10 percent from September 1990 under Diagnostic Code 5003 criteria. In December 1993 a 10 percent rating was assigned from September 1990 for residuals of the left humerus fracture under Diagnostic Code 5203 criteria. Lay statements in early 1995 report observations of the veteran's various joint complaints. A VA examiner in early 1995 opined that the veteran was prone to exaggerate complaints referable to the musculoskeletal system. He showed a normal gait, no external abnormality of the hands, some lateral instability of the knees and a scar on the left shoulder that was not mentioned again. The veteran could not abduct the left arm more than 10 degrees above horizontal. The pertinent conclusions were degenerative changes of the left shoulder and the knees consistent with earlier reports and post-traumatic change of the right fifth finger. Other clinical records received show in September 1997 a complaint of knee pain and note the veteran's work as a fireman. He was found to have a full range of motion of the knees. He stated that his knees bothered him occasionally. The assessment included osteoarthritis occasionally. A November 1997 statement from his employer noted physical activity limitations for the veteran and the consequences in the workplace. VA examination of the veteran in September 1998 included a review of the claims file and the Board remand. He reported that the present symptoms were not changed but were problematic in his lifestyle and current vocation. He reported problems at work grasping with his hands and knee pain that prevented long kneeling. He reported that he used kneepads and that left shoulder discomfort more so than fatigue required him to rest the shoulder. Examination of the hands showed range of motion within normal limits for the joints except for the fifth finger proximal interphalangeal joint on each hand and 10 degrees of ulnar deviation of the bilateral second and third digits at the proximal interphalangeal joint. Motor strength for grip, wrist extension and flexion, ulnar and radial deviations including apposition of the fingers was reported as 5/5. The examiner found that the prolonged effort fell short of a normal examination and the veteran described discomfort especially in abduction and adduction of the fingers and prolonged handgrip. The sensory examination was intact to light touch and no other deformity was noted. Regarding the left shoulder, the examiner reported decreased range of motion with internal rotation 75-80 degrees, external rotation limited to 85 degrees and abduction just shy of 90 degrees. The veteran could equally internally rotate and extend the shoulder with elbow flexion bilaterally. He reportedly had difficulty performing bilateral hands behind head specifically due to discomfort and decreased range of motion of the left shoulder. Biceps and triceps and elbow pronation and supination of the forearm was rated as 5/5. The cross-chest adduction and external and internal rotation of left shoulder limited by discomfort in that position and not by range of motion. Concerning the knees, the examiner found a full active range of motion with 5/5 flexor and extensor strength and no abnormal varus or valgus laxity. There was no pivot shift but the veteran did have positive crepitus upon balloting of the patellae. The examiner found no sign of erythema or effusion or deformities. Deep tendon reflexes at the patella were not performed due to knee discomfort. The examiner reported no overt weakness of excess fatigability or incoordination in the hands, left shoulder or the knees. The examiner stated that the veteran did have limited range of motion and duration of range of motion, and duration of 5/5 strength in these areas associated with the respective diagnoses. The examiner noted that the veteran's work required him to be fully mobile and perform extended tasks with these joints but that the veteran stated he was adequately compensated by wearing knee pads and resting the hands and the shoulder as necessary. The examiner indicated that the full severity could not be quantified but there was the expected guarding of the left shoulder and mildly decreased range of motion but with adequate strength within the range of motion that he did have. There were no signs of muscle atrophy or any other signs of atrophy. The examiner stated that the limitation of motion, prolonged effort and grip with abduction and adduction of the fingers of both hands were manifestations of the service-connected disability. The examiner stated that the service-connected disabilities did not cause excess fatigability or incoordination at the time of the examination but that there was positive crepitus with balloting of the patella. The examiner stated further that discomfort was experienced with hand behind the head maneuver due to discomfort and decreased range of motion of the left shoulder and again restated the findings for the cross-chest adduction with internal and external rotation of the left shoulder. The examiner mentioned the tenderness over the patella with balloting and the inability to test deep tendon reflexes of the knees due to discomfort. The examiner stated there were no clinical findings that identify an increased impairment of use of the hands and shoulders and that the full severity of the knees, hands and shoulder could not be quantified. Criteria Disability evaluations are based on the comparison of clinical findings to the relevant schedular criteria. 38 U.S.C.A. § 1155. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Both the use of manifestations not resulting from service- connected disease or injury in establishing the service- connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14 (1998). Although a review of the recorded history of a disability is necessary in order to make an accurate evaluation, see 38 C.F.R. §§ 4.2, 4.41 (1998), the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. As regards the joints the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.). (b) More movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.). (c) Weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.). (d) Excess fatigability. (e) Incoordination, impaired ability to execute skilled movements smoothly. (f) Pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. For the purpose of rating disability from arthritis, the shoulder, elbow, wrist, hip, knee, and ankle are considered major joints; multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities, the interphalangeal, metatarsal and tarsal joints of the lower extremities, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae, are considered groups of minor joints, ratable on a parity with major joints. The lumbosacral articulation and both sacroiliac joints are considered to be a group of minor joints, ratable on disturbance of lumbar spine functions. 38 C.F.R. § 4.45. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Arthritis, degenerative (hypertrophic or osteoarthritis): Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, rate as below: With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, 20 percent. With X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent. Note (1): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. Diagnostic Code 5003. The following diseases listed under diagnostic codes 5013 through 5024, respectively, Osteoporosis, with joint manifestations; Osteomalacia; Bones, new growths of, benign, Osteitis deformans, Gout, Hydrarthrosis, intermittent, Bursitis, Synovitis, Myositis, Periostitis, Myositis ossificans and Tenosynovitis will be rated on limitation of motion of affected parts, as arthritis, degenerative, except gout which will be rated under diagnostic code 5002. In exceptional cases where the schedular evaluations are found to be inadequate, an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be approved provided the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalizations as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). When a claimant is awarded service connection for a disability and subsequently appeals the RO's initial assignment of a rating for that disability, the claim continues to be well-grounded as long as the rating schedule provides for a higher rating and the claim remains open. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that a claim such as the veteran's is properly framed as an appeal from the original rating rather than a claim for increase but that in either case the veteran is presumed to be seeking the maximum benefit allowed by law or regulations. In Fenderson it was held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder and that in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period, classified as "staged ratings". Arm (minor), limitation of motion to 25° from side shall be rated 30 percent. Midway between side and shoulder level or at shoulder level warrants a 20 percent evaluation. Diagnostic Code 5201. Arm (major), limitation of motion to 25° from side, shall be rated 40 percent. Midway between side and shoulder level shall warrant a 30 percent evaluation. At shoulder level, a 20 percent may be assigned. Diagnostic Code 5201. Other impairment of the humerus (major/minor) manifested by loss of head (flail shoulder) shall be rated 80/70 percent. With nonunion (false flail joint) a 60/50 percent rating is provided. Fibrous union shall be rated 50/40 percent. Malunion with marked deformity shall be rated 30/20 percent and with moderate deformity 20/20 percent. Recurrent dislocation at the scapulohumeral joint with frequent episodes and guarding of all movements shall be rated 30/20 percent and 20/20 with infrequent episodes and guarding of movement at shoulder level. Diagnostic Code 5202. Impairment of the clavicle or scapula (major or minor), dislocation shall be rated 20 percent. Nonunion, with loose movement shall be rated 20 percent, and without loose movement, 10 percent. Malunion shall be rated 10 percent. Or rate on impairment of function of contiguous joint. Diagnostic Code 5203. Plates I and II provide a standardized description of ankylosis and joint motion measurement; for the shoulder, forward elevation (flexion) and abduction 0 to180 degrees, internal rotation 0 to 90 degrees and external rotation 0 to 90 degrees. The anatomical position is considered as 0°, with two major exceptions: (a) Shoulder rotation-arm abducted to 90°, elbow flexed to 90° with the position of the forearm reflecting the midpoint 0° between internal and external rotation of the shoulder; and (b) supination and pronation-the arm next to the body, elbow flexed to 90°, and the forearm in mid- position 0° between supination and pronation. 38 C.F.R. § 4.71. Other impairment of the knee, recurrent subluxation or lateral instability that is severe shall be rated 30 percent, if moderate, 20 percent and if slight, 10 percent. Diagnostic Code 5257. Cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint shall be rated 20 percent. Diagnostic Code 5258. Limitation of flexion of the leg to 15°shall be rated 30 percent. Flexion limited to 30° shall be rated 20 percent. Flexion limited to 45° shall be rated 10 percent. Flexion limited to 60° shall be rated 0 percent. Diagnostic Code 5260. Limitation of extension of the leg to 45° shall be rated 50 percent. Extension limited to 30° shall be rated 40 percent. Extension limited to 20° shall be rated 30 percent. Extension limited to 15° shall be rated 20 percent. Extension limited to 10° shall be rated 10 percent and extension limited to 5° shall be rated 0 percent. Diagnostic Code 5261. Plates I and II provide a standardized description of ankylosis and joint motion measurement that for the knee is flexion 140 degrees and extension 0 degrees. 38 C.F.R. § 4.71, Plate II. Ankylosis of the knee extremely unfavorable, in flexion at an angle of 45° or more shall be rated 60 percent. In flexion between 20° and 45° shall be rated 50 percent. In flexion between 10° and 20° shall be rated 40 percent. Favorable angle in full extension, or in slight flexion between 0 and 10° shall be rated 30 percent. Diagnostic Code 5256. Analysis As a preliminary matter, the Board finds that the veteran's claim for increased disability compensation is well grounded. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995); Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is satisfied that all relevant facts have been properly developed to the extent possible and that no further duty to assist exists with respect to the claim. The veteran has been provided comprehensive evaluations in connection with the claim and other records have been obtained as the Board asked for in remanding the case. Stegall v. West, 11 Vet. App. 268 (1998). The RO had a medical evaluation that addressed the provisions of 38 C.F.R. §§ 4.40 and 4.45 and comment on the extent of functional loss as discussed in DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). It was the holding in Johnson v. Brown, 9 Vet. App. 7, 10 (1996), that functional loss due to pain will be rated at the same level as the functional loss where motion is impeded. The disability of the left humerus is rated currently in accordance with the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5203, which assess basically movement characteristics of malunion or nonunion as the primary rating criteria for the incremental ratings of 10 and 20 percent for the minor or nondominant extremity. The rating scheme allows for the application of Diagnostic Code 5201, which provides for characteristic movement limitation of motion of the arm with incremental ratings from 20 to 30 percent. The Board finds the rating scheme for limitation of motion appropriate for the veteran's disability in view of the diagnosis for the left humerus symptomatology. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992); 38 C.F.R. §§ 4.20, 4.21. Recurrent dislocation has not been reported which appears to make the choice of the current rating scheme more appropriate than the initially selected rating scheme under Diagnostic Code 5202. The Board also observes that an analogous rating application to ankylosis under Diagnostic Code 5200 would be inapplicable in view of the findings on examinations since service. The Board is satisfied that the record establishes the veteran's left hand as the dominant extremity. 38 C.F.R. § 4.69. The Board observes that the RO has assigned a 10 percent evaluation based upon the recent VA examination which did report limitation of motion, as the range of motion recorded showed significant disparity from the normal range of motion contemplated in the standardized description of shoulder motion in the rating schedule. It appears that the range of motion has been appreciably limited, approximating shoulder level. This has been a consistent finding along with complaints of pain and functional limitation. Applying this information to the rating schedular criteria leads the Board to conclude that an increased evaluation is warranted for the left shoulder. The shoulder symptoms have not shown appreciable difference on the comprehensive examinations and, overall, do appear to more nearly approximate a 20 percent evaluation for the major extremity. The rating scheme does not require a mechanical application of the schedular criteria, but applying the rating schedule liberally results in a 20 percent evaluation recognizing a symptomatic left shoulder characterized by pain and demonstrable limitation of motion that would likely impact the veteran adversely with activity that would occur in the workplace. In fact the veteran did report the means he used to overcome hand and knee problems experienced with job related tasks. The recent examination findings clearly support a conclusion that the veteran's left shoulder disorder is productive of disability characterized by appreciable objective findings. It cannot be overlooked that range of motion on the recent VA examination showed an appreciable loss from the previous examinations and a significant loss from the norm. Thus, the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint would clearly be appropriate in the veteran's case and allow for at least a 10 percent rating applying § 4.59. The extent of the limitation of motion particularly in abduction would more clearly approximate the criteria for a 20 percent evaluation for the joint in view of the interplay of §§ 4.40, 4.59 and Diagnostic Code 5201. The recent VA examinations appear to have clearly addressed the veteran's complaints and reported objective manifestations likely related to the disability. In view of the foregoing, the Board concludes that the evidence more nearly approximates a 20 percent rating for the left shoulder for the entire period of this appeal. 38 C.F.R. § 4.7. Clearly, the objectively confirmed manifestations that would support a higher evaluation under any rating scheme applicable to the disability are not shown. Examiners have not confirmed a neurologic component of the disability nor was there any quantifiable measure of additional range of motion lost with exacerbations. However, the examiners have not suggested that the range of motion would be so limited as to meet or more nearly approximate the criteria for the next higher evaluation of 30 percent under Diagnostic Code 5201. In addition the provisions of 38 C.F.R. §§ 4.40 and 4.45 as they relate to pain and factors other than limitation of motion as described on two VA examinations appear to support no more than a 20 percent rating. The Board must point out that the VA examinations are consistent in the objective findings for the left shoulder and the disability appears to have been essentially little changed from the standpoint of limitation of motion. There is appreciable limitation of motion but appreciable manifestations that complement the range of motion for the shoulder appear to place the preponderance of the evidence against the claim for a rating in excess of 20 percent. Specifically, the recent examinations did not confirm disuse, weakened movement, excess fatigability or incoordination. The Board observes that the RO has assigned a 10 percent evaluation for the knees and the hands combined based upon X- ray evidence of arthritis rather than limitation of motion criteria. The Board finds that separate ratings are warranted since VA examinations have noted collectively appreciable crepitus, range of motion slightly less than the norm when it is compared to the standardized description of knee motion in the rating schedule and instability. The veteran's left knee disability may be rated in accordance with the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5257, which assess basically the level of orthopedic disturbance from subluxation or lateral instability as primary rating criteria for the incremental ratings from 10 to 30 percent. The Board finds a different rating scheme more appropriate for the veteran's disability in view of the diagnosis for the knee and symptomatology. 38 C.F.R. §§ 4.20, 4.21. There is arthritis that requires an application of limitation of motion criteria which cannot be combined with a rating based on X-ray evidence only. Applying this information to the rating schedule criteria leads the Board to conclude that an increased evaluation is warranted for the knees based upon separate 10 percent ratings. There has been no distinction made on any examination between the knees. The knee symptoms, overall, do appear to more closely approximate a level of impairment contemplated in a schedular evaluation of 10 percent. The rating scheme does not require a mechanical application of the schedular criteria, and here applying the rating schedule liberally results in a 10 percent evaluation recognizing persistently symptomatic knees characterized by painful motion and crepitation but not instability or limitation of motion currently. Although limitation of motion and some instability were mentioned on earlier examinations, the symptoms were not consistent then and current neither was shown on a comprehensive examination. Other clinical records fail to confirm limitation of motion or instability. The objective examination findings clearly support a conclusion that the veteran's disorder is productive of an appreciable disability of each knee. The Board observes that overall the manifested tenderness and crepitus with pain supports separate a 10 percent evaluation for each knee. The intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint would clearly be appropriate in the veteran's case and allow for a 10 percent rating under 38 C.F.R. § 4.59. The recent VA examination appears to have clearly addressed the veteran's complaints and reported objective manifestations likely related to the disability. The more recent statements of functional limitation in the workplace are pertinent to the disability evaluation. The record does not confirm recurrent subluxation or lateral instability. The Board notes that arthritis is a component of the disability thereby requiring the application of limitation of motion criteria and consideration of other rating factors in 38 C.F.R. §§ 4.40, 4.45 and 4.59. The Board is aware of the recently issued precedent opinion of the VA General Counsel that authorizes multiple ratings for a disability where there is additional disability currently existing characterized by different manifestations. VAOPGCPREC 23-97. See also VAOPGCPREC 9-98. The Board is bound by precedent opinions of the VA General Counsel. 38 U.S.C.A. § 7104(c). The facts of this case do not support the assignment of multiple ratings. However, the current rating should account for the demonstrable functional impairment and crepitus shown that otherwise would not be compensable under the specific rating criteria for limitation of motion. The veteran's testimony has supplemented the record and is consistent with an appreciable disability shown objectively. The examinations and other recent medical reports are significant from the standpoint of functional loss linked in part to the disability of the knees. No examiner has equated the level of impairment to loss of use that would support by analogy a 40 percent rating. See for example 38 C.F.R. § 4.63 and Diagnostic Code 5167. Examinations have not shown ankylosis of either knee, thereby precluding assignment of a higher evaluation under diagnostic code 5256. In view of the foregoing discussion, the Board concludes that the evidentiary record supports a grant of entitlement to an increased evaluation of not more than 10 percent for either knee with application of all pertinent governing criteria for the entire rating period. Turning to the arthritis of the hands, the disability must be evaluated under the limitation of motion criteria as it cannot be combined with the knees and ratings must coincide. The musculoskeletal rating scheme does not provide for hand disability other than by recognizing loss of use, which is not shown here, or limitation of motion or ankylosis for various combinations of fingers. However, an appreciable but slight limitation of motion is not considered compensable. See note preceding Diagnostic Code 5216; see also the note following Diagnostic Code 5309 regarding analogous functional impairment of the hand from muscle injury. The recent VA examination evaluated the hands thoroughly and from the examiner's discussion of symptoms it appears that a 10 percent rating is warranted for the decreased strength and grip and increased effort. Although there were no overt signs of incoordination, excess fatigability or weakness, the examiner stated that the limitation of motion, prolonged effort and grip with abduction and adduction of the fingers of both hands were manifestations of the service-connected disability. Thus the disability should be rated inn accord with the holding in Johnson that functional loss due to pain will be rated at the same level as the functional loss where motion is impeded. There is satisfactory evidence of painful motion in the limitation of function described on the recent VA examination. Therefore giving consideration to the rating factors in 38 C.F.R. §§ 4.40, 4.45 and 4.59, the Board finds that a 10 percent rating for each hand is warranted for the entire period of this appeal is warranted. The Board notes that although the decision herein included consideration of the holding in Fenderson, the veteran has not been prejudiced by such discussion in view of the decision on the merits. See for example Bernard v. Brown, 4 Vet. App. 384, 392-394 (1993). The disability of the cervical spine and the shoulders did not warrant consideration of staged ratings in view of facts specific to each disability. Extraschedular Rating It is provided under 38 C.F.R. § 3.321(a) that the provisions contained in the rating schedule will represent as far as can practicably be determined, the average impairment in earning capacity in civil occupations resulting from disability. And under § 3.321(b)(1) there is an additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. The governing norm in these exceptional cases is a finding that the 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. Generally, the degrees of disability specified under the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbation or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. The veteran's well-documented medical history in VA medical treatment records shows the knees, hands and the left shoulder have been afforded treatment. There is also evidence of current employment and statements and testimony of limitations in the workplace imposed by the disabilities. Consideration is warranted under the principles established in Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The Board would point out that the exceptional or unusual disability picture mentioned in the regulation would reasonably contemplate factors other than marked interference with employment or frequent periods of hospitalization. Johnston v. Brown, 10 Vet. App. 80, 86 (1997). However, such factors would be apparent from the record and necessarily relate to the service-connected disability. See, e.g., Smallwood v. Brown, 10 Vet. App. 93, 97-98 (1997) and Spurgeon v. Brown, 10 Vet. App. 194, 197 (1997). There does not appear to be probative evidence that any nonservice- connected disorders affect his knees, hands or left shoulder in such a manner to render impractical the application of the regular schedular standards. See for example Johnston, 10 Vet App. at 86-89. The regulation provides for an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities, which in this case concerns bilateral knee and hand disorders and a left shoulder disability. The pertinent part of the regulation, though somewhat ambiguously worded, appears to contemplate an individual rather than a collective disability assessment. However, the components individually or collectively do not appear to meet essential criteria. Further, the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation is to be avoided. 38 C.F.R. § 4.14. This admonition could be read to apply to an extraschedular service-connected evaluation. However, in the case at hand, there is nothing probative to support a finding that the veteran has such an unusual or exceptional disability picture as a result of the service-connected disabilities considered. The most recent examination report, which confirms work that is presumed to be full-time as it not otherwise described does not establish an exceptional or unusual disability picture as a result of the disabilities. Indeed, the veteran informed the examiner of the rest requirements at work and in essence commented on the means taken to deal with the arthritis and left shoulder symptoms. Further, the Board does not find any extraneous circumstances that could be considered exceptional or unusual such as were present in Fisher v. Principi, 4 Vet. App. 57, 60 (1993) to warrant a different result in view of the veteran's work history and treatment for his service-connected disability components as reflected in the record. See also Fleshman v. Brown, 9 Vet. App. 548, 552-53 (1996); Shipwash, 8 Vet. App. at 227. ORDER Service connection for amblyopia of the left eye is denied. Service connection for headaches is denied. An initial rating of 20 percent for residuals, fracture of the left humerus is granted subject to the regulations governing the payment of monetary awards. An initial rating of 10 percent for arthritis of the left knee is granted subject to the regulations governing the payment of monetary awards. An initial rating of 10 percent for arthritis of the right knee is granted subject to the regulations governing the payment of monetary awards. An initial rating of 10 percent for arthritis of the left hand is granted subject to the regulations governing the payment of monetary awards. An initial rating of 10 percent for arthritis of the right hand is granted subject to the regulations governing the payment of monetary awards. Mark J. Swiatek Acting Member, Board of Veterans' Appeals