Citation Nr: 0004411 Decision Date: 02/18/00 Archive Date: 02/23/00 DOCKET NO. 97-29 046A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for a bilateral ankle disorder, claimed as secondary to the veteran's service- connected bilateral foot disorder. 2. Entitlement to service connection for a bilateral knee disorder, claimed as secondary to the veteran's service- connected bilateral foot disorder. 3. Entitlement to service connection for a bilateral hip disorder, claimed as secondary to the veteran's service- connected bilateral foot disorder. 4. Entitlement to service connection for a low back disorder, claimed as secondary to the veteran's service-connected bilateral foot disorder. 5. Entitlement to an increased rating for a bilateral foot disorder, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD Richard Giannecchini, Associate Counsel INTRODUCTION The veteran had active military service from July 1942 to January 1946. A perfected appeal to the Board of Veterans' Appeals (Board) of a particular decision entered by a Department of Veterans Affairs (VA) regional office (RO) consists of a Notice of Disagreement (NOD) in writing received within one year of the decision being appealed and, after a Statement of the Case (SOC) has been furnished, a substantive appeal (VA Form 9) received within 60 days of the issuance of the Statement of the Case or within the remainder of the one-year period following notification of the decision being appealed. With respect to the issues of service connection for a bilateral ankle disorder, bilateral knee disorder, bilateral hip disorder, and low back disorder, all claimed as secondary to the veteran's bilateral foot disorder, the present appeal arises from a November 1998 rating decision in which the RO denied the veteran's claims. The veteran filed an NOD in December 1998, and the RO issued an SOC in January 1999. The veteran filed a substantive appeal in April 1999. Supplemental statements of the case (SSOC) were issued in April, June, and August 1999. With respect to an increased rating for a bilateral foot disorder, the present appeal arises from an August 1997 rating decision in which the RO denied the veteran's claim. The veteran filed an NOD in September 1997, and the RO issued an SOC the following month. The veteran filed a substantive appeal in October 1997. In December 1998, the veteran testified before a hearing officer at the VARO in Pittsburgh. An SSOC was issued in January 1999. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. Service connection is currently in effect for a bilateral foot disorder, with a 30 percent disability evaluation assigned. 3. In December 1944, the veteran was noted to suffer from hallux valgus and chronic arthritis, as documented in an Office of the Surgeon General hospital admission card data file. 4. The veteran's first clinically documented post-service complaints of arthritis occurred in 1966, some 20 years after he separated from active service. 5. During a VA examination in September 1998, an examiner opined that, given the presence of chondrocalcinosis and generalized arthritic changes, to include those in the veteran's hands and neck, which would not be influenced by his gait, the veteran's problems with his spine, knees, and hips were caused by normal wear and tear and the metabolic presence of chondrocalcinosis, and were not related to his service-connected bilateral foot disorder. 6. There is no competent evidence of record that the veteran's arthritis of the ankles, knees, hips, and lumbosacral spine are due to disease or injury in service, or are secondary to his service-connected bilateral foot disorder. 7. The veteran has not submitted competent evidence sufficient to justify a belief by a fair and impartial individual that his claims for service connection for arthritis of the ankles, knees, hips, and lumbosacral spine, either on a direct basis or as secondary to a service-connected bilateral foot disorder, are plausible under the law. 8. Upon VA examination in December 1997, the veteran's right foot reflected clawing of the second through the fifth toes, slight valgus positioning of the great toe, and slight flattening of the longitudinal arch, and there were no areas of pain, tenderness, or loss of skin; evaluation of the left foot revealed clawing of the second through the fifth toes, valgus positioning of the great toe, and flattening of the longitudinal arch, with crepitation and stiffness. 9. The veteran's bilateral foot disorder does not reflect marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, and marked varus deformity. CONCLUSIONS OF LAW 1. The veteran has not submitted a well-grounded claim for service connection for a bilateral ankle disorder. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.310 (1999). 2. The veteran has not submitted a well-grounded claim for service connection for a bilateral knee disorder. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.310 (1999). 3. The veteran has not submitted a well-grounded claim for service connection for a bilateral hip disorder. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.310 (1999). 4. The veteran has not submitted a well-grounded claim for service connection for a low back disorder. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.310 (1999). 5. The criteria for an increased rating greater than 30 percent for a bilateral foot disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5278 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Basis A review of the claims file reflects that the veteran's service medical records were not available for review, having apparently been destroyed by a fire at the National Personnel Records Center (NPRC), which is not a VA facility. However, morning reports, dated in September 1943, November 1943, and December 1943, were obtained by the RO, and these records indicate that the veteran reported to sick call on a number of occasions, and was also shown to have been hospitalized. What the veteran was treated for was not reported. In March 1977, the veteran submitted to the RO a VA Form 21- 526 (Veteran's Application for Compensation or Pension), in which he filed a claim for service connection for a bilateral foot disorder. Also in March 1977, the RO received a statement from Alanson Hibbard, M.D, dated in February 1977. Dr. Hibbard noted that the veteran had come under his care in 1966, at which time he demonstrated painful swelling of his fingers, wrists, feet, and ankles. In April 1977, the RO received Meadville City Hospital treatment records, dated from December 1976 to January 1977. These records noted the veteran's complaints of, and treatment for left knee pain. In particular, in December 1976, the veteran was reported to have jumped off the back of a pickup truck, which resulted in an injury to his left knee. A subsequent open reduction and internal fixation of the left patella was performed. A January 1977 treatment record noted the veteran as suffering from arthritis in his right ankle. In December 1978, the veteran underwent VA medical examination. In particular, radiographic studies revealed arthritic changes in the lumbar spine, hands, and knees. The findings were noted as being consistent with a combination of rheumatoid arthritis and psoriatic arthritis, reported as mixed arthridities. In March 1984, the RO received medical records from the Erie VA Medical Center (VAMC), dated from May 1976 to April 1983. In particular, an X-ray report, dated in May 1976, revealed considerable arthritic changes at the metatarsophalangeal joints of the great toes. There was also arthritic change at the metatarsophalangeal joint of the left second toe. A treatment record, dated in February 1981, noted a finding of degenerative arthritis of the veteran's lumbar and cervical spine. A hospital summary, dated January 1982 to February 1982, reported the veteran to be suffering from cervical radiculopathy, as well as traumatic arthritis of the right ankle. A radiographic report with respect to the right ankle, dated in February 1982, noted an old injury to the distal fibula and talus, with development of traumatic arthritis. An operative report, dated in July 1982, noted the veteran as undergoing a compression arthrodesis of the right ankle, with Charnley pins and application of a posterior splint. In March 1989, the RO received information with respect to the veteran's service medical history from the National Archives and Records Administration. The information was noted to have been obtained from the Hospital Admission Card data files created by the Office of the Surgeon General, Department of the Army. This information noted that, in April 1944, the veteran had been admitted to the hospital and been diagnosed with "chronic arthritis, type unspecified". In December 1944, the veteran had again been admitted to the hospital and been diagnosed with Hallux valgus and "chronic arthritis, type unspecified". Thereafter, by a decision of the Board in April 1992, the veteran was service connected for a bilateral foot disorder, to include arthritis, status post bunion removal, and a resection of the metatarsal head of the right great toe. In August 1992, the veteran was medically examined for VA purposes. He complained of an aching pain in his feet which occurred when he walked, and also reported that he could not walk more than a block before having to stop. He was noted not to wear any orthosis or special shoes. Following a clinical evaluation, the examiner's diagnosis was bilateral cavus deformity with hallux valgus of the left foot and right ankle arthrodesis. By September 1992 rating action, the RO granted the veteran a 30 percent disability rating for a bilateral foot disorder, manifested by arthritis, status post bunion removal, and status post resection of the metatarsal head of the right great toe. In July 1994, the veteran's feet were examined by VA. The veteran complained of pain in both his feet on weightbearing. On clinical evaluation, there were bilateral claw toes of all five toes of both feet. The veteran was noted to walk symmetrically with both feet inverted and slightly externally rotated, putting most of his weight on his heels and rocking forward just slightly onto the forefoot. There was a large hallux valgus primus referable to the left foot. There was no sensory or circulatory deficit, both feet were stiff to palpation, and there was no actual loss of toe motion. The examiner's impression was hallux valgus of the left foot, and bilateral claw toes secondary to arthritic changes. That same month, the veteran also underwent VA examination of the joints. He complained of pain in his feet and knees, as well as pain in his left shoulder, low back, and occasionally his neck. The examiner reported range of motion findings with respect to the veteran's ankles, knees, hips, and low back. No other clinical findings were made with respect to those areas. In December 1994, the RO received a VAMC Pittsburgh consultation report, dated in August 1994. The veteran was noted to complain of low back pain with radiation into his thigh. The examiner's assessment was mechanical back pain, with lumbar stenosis revealed by computed tomography (CT) scan. In July 1995, the veteran underwent an examination of his feet for VA purposes. He complained of aching pain in both his feet, and reported difficulty with shoe wear. On clinical evaluation, the veteran was noted to walk with both of his feet slightly inverted. There was a mild symmetrical bilateral cavus positioning of the mid tarsal region. A large swelling overlying the head of the first metatarsal of the left foot was noted with valgus positioning of the great toe of the left foot. The other four toes were parallel with the great toe. There was no evidence of either foot showing any nail or nail bed abnormalities, and there were no areas of tenderness, swelling, or induration. Slight hyperflexion positioning of the proximal interphalangeal joints of the second and third toes of the right foot were noted. There were no painful calluses or loss of motion, and sensation and circulation were normal. An associated radiographic study revealed moderately severe bilateral hallux valgus deformity with associated degenerative changes of the right and left first metatarsophalangeal joint, as well degenerative change of the left second metatarsophalangeal joint and left first tarsal metatarsal articulation. The examiner's impression was bunion of the left foot with bilateral arthritic deformities of the feet. In addition, radiographic studies of the cervical and lumbar spine, and left knee, dated in July 1995, revealed degenerative changes in those joints. A radiographic study of the left hip, dated in May 1995, revealed mild chronic change in the left sacroiliac joint, with no evidence of acute bony trauma. In August 1995, the RO received VAMC Erie medical records, dated from December 1994 to June 1995. These records noted the veteran's treatment for depression and coronary artery disease. In March 1997, the RO received a copy of statement written by Dr. Hibbard, dated in July 1978. Dr. Hibbard noted in his statement that the veteran suffered from generalized arthritic changes. He also noted that arthritis of the spine and extremities had progressed in spite of medications and the veteran was unable to stand, walk, or drive an automobile for any sustained period. Dr. Hibbard, in summary, reported that the veteran was permanently and totally disabled. That same month, the RO received a statement from Kenneth Challener, M.D., dated in March 1997. Dr. Challener reported that the veteran suffered from severe degenerative arthritis of the lumbosacral spine and left knee. He also noted that the veteran was very limited in terms of his activities. In October 1997, the veteran filed a claim of service connection for arthritis in his ankles, knees, hips, and low back, contending that the arthritis had resulted from the way he had been forced to walk all his life due to his service- connected bilateral foot disability. In December 1997, the RO received VAMC Erie medical records, dated from July 1994 to November 1997. In particular, these records noted the veteran's treatment for depression and angina. Also in December 1997, the veteran again underwent VA examination of his feet. Upon clinical evaluation, with respect to the right foot, there was clawing of the second, third, fourth, and fifth toes, with a slight valgus positioning of the great toe. Minimal prominence of the distal end of the first metatarsal was noted, as well as a well-healed fusion of the right ankle. There was slight flattening of the longitudinal arch; sensation and circulation were intact; and there were no areas of pain, tenderness, or loss of skin. Evaluation of the left foot revealed a large lateral and ventral protuberance of the first metatarsal head, with an area of glistening skin and minimal bursal formation overlying it. There was clawing of the second, third, fourth and fifth toes, with valgus positioning of the great toe. Flattening of the longitudinal arch was noted, with no sensory or circulatory problems. There was crepitation and stiffness, but no gross loss of ankle motion. In addition, the veteran underwent a joints examination, in which the examiner made findings with respect to the range of motion of the veteran's hips, knees, and lumbar spine. Associated radiographic studies revealed severe spondylosis in the lumbar spine, chondrocalcinosis with osteoarthritic changes in the left and right knees, right ankle arthrodesis with degenerative changes on the left, and severe hallux valgus deformity with degenerative changes of the first metatarsal phalangeal and interphalangeal joints. In February 1998, the RO received treatment records from Dr. Challener, some duplicative, dated from January 1995 to December 1997. In particular, treatment records noted degenerative changes in the veteran's left and right knees, left and right hip, and left and right shoulder. The veteran was also noted to complain of intermittent low back pain. In September 1998, the veteran was medically examined for VA purposes. He reported his medical history to include bunion surgery on his right foot in 1943. In addition, the veteran reported that he had suffered from some joint aches while in service, but that he had not sought treatment with respect to those problems. He complained of joint pain in his hands, ankles, hips, and entire spine, since service. He was reported to use a cane. On clinical evaluation, the veteran was noted to walk with a symmetrical slightly external rotated gait. Examination of the hips revealed some stiffness in the left hip as compared to the right, with slight areas of tenderness. There were no joint contractures or areas of tenderness. Evaluation of the knees revealed no malalignment or swelling, and both were reported stable. With respect to the low back, there was a flattening of the lumbar curve, and no spine or paravertebral tenderness or muscle spasm. The examiner's diagnostic impression was post patellectomy of left knee, with bilateral chondrocalcinosis of both knees; degenerative changes in the dorsolumbar and cervical spine; and post-fusion of right ankle with bilateral bunion formation of both feet, the left much more severe than the right. In addition, the examiner noted that he/she had considered whether the degenerative changes in the veteran's ankles, knees, hips, and lumbar spine were due to his altered gait caused by his bilateral foot condition. The examiner reported that, given the presence of the chondrocalcinosis and the generalized arthritic changes, including those of the hands and neck, which would not be influenced by the veteran's gait, that the veteran's arthritic problems in his lumbar spine, knees, and hips were caused by normal wear and tear, in addition to the metabolic presence of chondrocalcinosis, and were not related to his bilateral foot disorder. In December 1998, the veteran testified before a hearing officer at the VARO in Pittsburgh. The veteran's representative reported that the issue on appeal was actually a secondary service-connection claim with respect to the arthritic condition in the veteran's feet, and not the gait abnormality associated with the foot disorder. The veteran's representative further reported that the veteran's service medical records reflected findings of chronic arthritis. The veteran testified that, while in service, he had experienced some swelling in his joints. In addition to his testimony, the veteran submitted a copy of a page from the Merck Manual which discussed rheumatoid arthritis. In January 1999, the RO received a VAMC Erie radiographic report of the veteran's lumbar spine, dated that same month. The report's impression noted advanced diffuse acquired spinal stenosis. In April 1999, the RO received VAMC Erie medical records, dated from January to March 1999. In particular, these records noted the veteran's treatment for a chronic duodenal ulcer, as well as a finding that he suffered from advanced diffuse acquired spinal stenosis. II. Analysis a. Service Connection With regard to the veteran's appeal, the threshold question to be answered is whether he has presented well-grounded claims. 38 U.S.C.A. § 5107 (West 1991); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). If he has not, the claims must fail and there is no further duty to assist in their development. 38 U.S.C.A. § 5107; Murphy v. Derwinski, 1 Vet.App. 78 (1990). This requirement has been reaffirmed by the United States Court of Appeals for the Federal Circuit in its decision in Epps v. Gober, 126 F.3d 1464, 1469 (Fed. Cir. 1997). That decision upheld the earlier decision of the United States Court of Appeals for Veterans Claims (previously known as the Court of Veterans Appeals), which made clear that it would be error for the Board to proceed to the merits of a claim which is not well grounded. Epps v. Brown, 9 Vet.App. 341 (1996). The United States Supreme Court declined to review the case. Epps v. West, 118 S. Ct. 2348 (1998). See also Morton v. West, 12 Vet.App. 477, 480-1 (1999). The Court of Appeals for Veterans Claims has also held that, in order to establish that a claim for service connection is well grounded, there must be competent evidence of: (1) a current disability (a medical diagnosis); (2) the incurrence or aggravation of a disease or injury in service (lay or medical evidence); and (3) a nexus (that is, a connection or link) between the in-service injury or aggravation and the current disability. Competent medical evidence is required to satisfy this third prong. See Elkins v. West, 12 Vet.App. 209, 213 (1999) (en banc), citing Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). "Although the claim need not be conclusive, the statute [38 U.S.C.A. §5107] provides that [the claim] must be accompanied by evidence" in order to be considered well grounded. Tirpak v. Derwinski, 2 Vet.App. 609, 611 (1992). In a claim of service connection, this generally means that evidence must be presented which in some fashion links the current disability to a period of military service or to an already service-connected disability. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1999); Rabideau v. Derwinski, 2 Vet.App. 141, 143 (1992); Montgomery v. Brown, 4 Vet.App. 343 (1993). Evidence submitted in support of the claim is presumed to be true for purposes of determining whether it is well grounded. King v. Brown, 5 Vet.App. 19, 21 (1993). Lay assertions of medical diagnosis or causation, however, do not constitute competent evidence sufficient to render a claim well grounded. Grottveit v. Brown, 5 Vet.App. 91, 93(1992); Espiritu v. Derwinski, 2 Vet.App. 492, 495 (1992). To establish a 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. 38 C.F.R. § 3.303(b) (1999). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Under applicable criteria, service connection may be granted for a disability resulting from disease or injury which was incurred in, or aggravated by, service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 1998). A veteran shall be granted service connection for arthritis, although not otherwise established as incurred in service, if the disease is manifested to a compensable degree within one year following service. See 38 C.F.R. §§ 3.307, 3.309 (1999). In a claim for secondary service connection, the regulations 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 (1999). Secondary service connection may also be warranted for a non-service-connected disability when that disability is aggravated by a service-connected disability. Allen v. Brown, 7 Vet.App. 439 (1995) (en banc). The United States Court of Appeals for Veterans Claims has specifically held that "[a] claim for secondary service connection, like all claims, must be well grounded." Reiber v. Brown, 7 Vet.App. 513, 516 (1995). The Board is mindful that, in a case such as this, where service medical records have been lost, there is a heightened duty to assist the veteran in developing the evidence that might support his claim. O'Hare v. Derwinski, 1 Vet.App. 365, 367 (1991); Cuevas v. Principi, 3 Vet.App. 542, 548 (1992). This heightened duty in a case where service medical records are presumed destroyed includes the obligation to search for alternate medical records. Moore v. Derwinski, 1 Vet.App. 401, 406 (1991). The RO conducted an alternate search for the veteran's service medical records and was able to obtain various morning reports in addition to records from the Office of the Surgeon General. As will be discussed below, we find the RO has met the heightened duty to assist in this instance. We are aware that the veteran, in his original claim, filed in October 1997, sought service connection for arthritis of the ankles, knees, hips, and low back as secondary to his service-connected bilateral foot disorder. He reported that arthritis in these joints was a direct result of the way he had been forced to walk all his life due to his bilateral foot disability. Subsequently, during his personal hearing in December 1998, the veteran's representative reported that the veteran's claims were for secondary service-connection based on a relationship between the veteran's arthritis in his ankles, knees, hips, and low back, and the arthritis associated with his bilateral foot disorder. The Board notes that the records from the Office of the Surgeon General reflect treatment for chronic arthritis and hallux valgus. While it appears the reported chronic arthritis is associated with the veteran's foot disorder, this fact is not perfectly clear. We are cognizant that, on VA examination in September 1998, the veteran reported a history of joint swelling in service, but also indicated that he had not been treated for this problem while on active duty. Thus, based on the report of the veteran, additional copies of his service medical records, if found at another custodial facility, would not show evidence of treatment for arthritis of the ankles, knees, hips, or low back. We therefore conclude that any attempts above and beyond those undertaken by the RO are not warranted, and that the heightened duty to assist has been met. With this in mind, we now must assess whether the veteran's claims are well grounded. As noted above, the veteran was separated from service in January 1946, and reported that he was not treated in service for arthritis of his ankles, knees, hips, or lumbosacral spine. We note that the veteran currently suffers from arthritis of all these joints. Based upon Dr. Hibbard's report, the first documented treatment for arthritis began in 1966, some 20 years after the veteran separated from service. There is no other medical evidence of record documenting earlier treatment for the disease. Thus, the veteran has not submitted competent medical evidence that he incurred arthritis of the ankles, knees, hips, or low back during his active service. Furthermore, the veteran has not submitted any competent medical evidence, i.e., a nexus opinion, relating arthritis in his ankles, knees, hips and low back, to service. See Clyburn v. West, 12 Vet.App. 296, 301 (1999), holding that continued complaints of pain after service do not suffice to establish a medical nexus, where the issue at hand is of etiology, and requires medical opinion evidence. Although the veteran is competent to testify to the pain he has experienced since active service, he is not competent to testify to the fact that what he experienced in service and since service are the same related disorders. In addition, the medical evidence of record does not support a finding that arthritis of the ankles, knees, hips, or low back were manifested to a compensable degree within the one-year presumption period following service. See 38 C.F.R. §§ 3.307, 3.309 (1999). With respect to secondary service connection, after thorough review of the record, we find that there is also no competent evidence of record to support the veteran's contentions that his arthritis of the ankles, knees, hips, or low back resulted from his service-connected bilateral foot disorder. During a VA examination in September 1998, an examiner opined that given the presence of chondrocalcinosis, i.e., pseudogout, and the generalized arthritic changes, to include those in the veteran's hands and neck, which would not be influenced by his gait, the veteran's problems with his spine, knees, and hips were caused by normal wear and tear and the metabolic presence of chondrocalcinosis, and were not related to his bilateral foot disorder. We also find that the veteran has not submitted any competent medical evidence that the arthritis apparently identified in his feet during service caused or is directly related clinically to the arthritis in his ankles, knees, hips, and/or low back. The Board has considered the report of the metabolic presence of chondrocalcinosis in the veteran's system. However, whether chondrocalcinosis is the underlying cause of the veteran's arthritic condition in his feet has not been medically established by the evidence of record. Therefore, the veteran has not submitted evidence of a well- grounded claim, i.e., that the arthritis in his ankles, knees, hips, and low back, is related to his service connected bilateral foot disorder, or the arthritis associated with that foot disorder. See Caluza, supra. The veteran has been very specific in asserting that he suffers from service connected arthritic conditions in his ankles, knees, hips, and low back as secondary to his service-connected bilateral foot condition. While the Board does not doubt the sincerity of the veteran's contentions in this regard, and his belief that he suffers from service- related disabilities, our decision must be based on competent medical testimony or documentation. In a claim of service connection, this generally means that medical evidence must establish that a current disability exists, and that the disability is related to a period of active military service. Competent medical evidence has not been presented establishing that the veteran's arthritic changes in his ankles, knees, hips, and low back are service related, either on a direct basis or as secondary to his service-connected bilateral foot disorder. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999); Rabideau v. Derwinski, Montgomery v. Brown, both supra. Furthermore, the veteran does not meet the burden of presenting evidence of well-grounded claims merely by presenting his own testimony, because, as a lay person, he is not competent to offer medical opinions. See, e.g., Voerth v. West, 13 Vet. App. 117, 120 (1999) ("Unsupported by medical evidence, a claimant's personal belief, no matter how sincere, cannot form the basis of a well-grounded claim."). See Bostain v. West, 11 Vet.App. 124, 127 (1998), citing Espiritu, supra. See also Carbino v. Gober, 10 Vet.App. 507, 510 (1997); aff'd sub nom. Carbino v. West, 168 F.3d 32 (Fed. Cir. 1999); 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), cert. denied, 119 S. Ct. 404 (1998). Under the law, the veteran is free, at any time in the future, to submit new and material evidence to reopen his claims for bilateral ankle, knee, and hip disorders, as well as a low back disorder, on a direct basis or as secondary to his service-connected bilateral foot disorder, regardless of the fact that he currently is not shown to be suffering from disabilities that may be service-connected. Such evidence would need to show, through competent medical evidence, a current disability or disabilities, and that such disability, "resulted from a disease or injury which was incurred in or aggravated by service." 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999); Rabideau, Montgomery, supra. In absence of well-grounded claims, there is no duty to assist the veteran further in their development, and the Board does not have jurisdiction to adjudicate them. Morton, supra; Boeck v. Brown, 6 Vet.App. 14 (1993); Grivois v. Brown, 5 Vet. App. 136 (1994). Accordingly, as a claim that is not well grounded does not present a question of fact or law over which the Board has jurisdiction, the claims for service connection for bilateral ankle, knee, and hip disorders, as well as a low back disorder, either on a direct basis or secondary to the veteran's service-connected bilateral foot disorder, must be denied. See Epps v. Gober, supra. b. Increased Rating The veteran has submitted a well-grounded claim for an increased rating within the meaning of 38 U.S.C.A. § 5107(a). See Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990); Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). That is, the Board finds that he has submitted a claim which is plausible. This finding is based in part on the veteran's assertion that his service-connected bilateral foot disorder is more severe then previously evaluated. See Jackson v. West, 12 Vet.App. 422, 428 (1999), citing Proscelle v. Derwinski, 2 Vet.App. 629 (1992). The Board is also satisfied that all relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained, and that no further assistance is required to comply with the duty to assist him as mandated by 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and 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. 38 C.F.R. §§ 3.102, 4.3, 4.7 (1999). The RO has assigned a 30 percent evaluation for a bilateral foot disorder, in accordance with the criteria set forth in the VA Schedule for Rating Disabilities. In doing so, specific consideration was given to 38 C.F.R. Part 4, Diagnostic Code (DC) 5278, "Claw foot (pes cavus), acquired." Under DC 5278, where the disorder is bilateral, a 30 percent rating is provided with all toes tending to dorsiflexion, limitation of dorsiflexion at the ankle to right angle, a shortened plantar fascia, and marked tenderness under the metatarsal heads. A 50 percent rating is warranted with marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, and marked varus deformity. 38 C.F.R. § 4.71a, DC 5278 (1999). During the veteran's most recent VA examination in December 1997, with respect to the right foot, there was clawing of the second, third, fourth, and fifth toes, with a slight valgus positioning of the great toe. Minimal prominence of the distal end of the first metatarsal was noted, as well as a well-healed fusion of the right ankle. There was slight flattening of the longitudinal arch; sensation and circulation were intact; and there were no areas of pain, tenderness, or loss of skin. Evaluation of the left foot revealed, a large lateral and ventral protuberance of the first metatarsal head, with an area of glistening skin and minimal bursal formation overlying it. There was clawing of the second, third, fourth and fifth toes, with valgus positioning of the great toe. Flattening of the longitudinal arch was noted, with no sensory or circulatory problems. There was crepitation and stiffness, but no gross loss of ankle motion. When we consider the most recent clinical evidence in relation to the rating criteria, the Board finds that the veteran's bilateral foot disorder does not demonstrate marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, and marked varus deformity, to warrant an increase to 50 percent under 38 C.F.R. § 4.71a, DC 5278 (1999). The Board has also considered other Codes associated with disabilities of the feet (DC's 5276-5284), to assess whether they would be applicable to the veteran's claim and afford him an opportunity for a higher disability rating. We note that, under DC 5284, "Foot injuries, other", a 40 percent disability rating is allowable for actual loss of use of a foot. The veteran still has use of his feet, and therefore this Code is not applicable to his claim. Under DC 5276, "Flatfoot, acquired", a 50 percent rating would be allowed for pronounced flatfoot, marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or manipulation. In this instance, the record does not reflect that the veteran's bilateral foot disability evidences the criteria for a 50 percent rating under DC 5276, and therefore this Code is also not applicable to his claim. Furthermore, while the veteran has complained of increased foot pain while walking, when we consider his bilateral foot disability in relation to the overall rating criteria for disabilities of the feet, we find the current rating more than adequately compensates him for his disability. In reaching this conclusion, we note that the criteria for rating foot injuries allows for a 20 percent rating when there is a moderately severe injury. The term "moderately severe" is not defined by regulation in this context. However, the Board is cognizant that the overall regulatory scheme relating to the feet and toes contemplates a 20 percent ratings in a case where problems include dorsiflexion of "all" toes unilaterally and marked tenderness under the metatarsal heads. 38 C.F.R. § 4.71a, DC 5278 (1999) (no more than 10 percent is warranted even if the great toe is dorsiflexed, and there is definite tenderness under the metatarsal heads). See also DC 5276 (1999) (no more than 10 percent is warranted when there is pain on manipulation and use of the feet, bilateral or unilateral). Consequently, an increase rating under DC 5278, or any other Code associated with disabilities of the feet, is not warranted. The Board is also cognizant that X-rays have established evidence of degenerative changes in both the right and left 1st metatarsal phalangeal (MTP) joint, in addition to the left 2nd MTP joint. With regard to rating disabilities involving the substantiated presence of degenerative or traumatic arthritis, DC 5003 provides that arthritis will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved (DC 5250 et seq.), and that limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When the rating based on limitation of motion is noncompensable under the appropriate diagnostic codes, a 10 percent rating for each major joint or group of minor joints affected by limitation of motion should be assigned; the 10 percent rating is not to be combined with, nor added to, Diagnostic Code 5003. In the absence of limitation of motion, a 20 percent rating will be assigned if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations; a 10 percent rating will be assigned if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. In this instance, the Board finds that an additional 10 percent rating for degenerative changes in both the right and left 1st MTP joint in addition to left 2nd MTP joint is not warranted under DC 5003, as a separate disability rating may be assigned under this Code only if degenerative changes affect 2 or more major joints, or 2 or more minor joint groups. In this case, the service-connected disability is manifested by multiple involvement of the MTP joints, and as such are considered only one minor joint group. See 38 C.F.R. § 4.45 (1999). Furthermore, while DC 5278 is not predicated on limitation of motion, the Board notes that the functional loss attributable to pain on use has been considered in arriving at the current assessment. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (1999); Johnson v. Brown, 9 Vet.App. 7, 11 (1996); DeLuca v. Brown, 8 Vet.App. 202, 206-207 (1995). The Board has also considered the benefit of the doubt under 38 U.S.C.A. § 5107 (West 1991 & Supp. 1998) and 38 C.F.R. §§ 3.102, 4.3 (1999), but the evidence is not in approximate balance so as to warrant its application. The Board also finds that the evidence of record does not present such ""an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1) (1999). We do sympathize with the veteran's assertions that he suffers from pain in his feet, and that this limits his ability to walk and partake in various activities. In this regard, the evidence does not show that the veteran's disorder has markedly interfered with his earning capacity or employment status, or has necessitated frequent periods of hospitalization. In the absence of such factors, the Board finds that the criteria for submission for consideration of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet.App. 337, 338-339 (1996); Shipwash v. Brown, 8 Vet.App. 218, 227 (1995). ORDER 1. Service connection for a bilateral ankle disorder, claimed as secondary to the veteran's service-connected bilateral foot disorder, is denied. 2. Service connection for a bilateral knee disorder, claimed as secondary to the veteran's service-connected bilateral foot disorder, is denied. 3. Service connection for a bilateral hip disorder, claimed as secondary to the veteran's service-connected bilateral foot disorder, is denied. 4. Service connection for a low back disorder, claimed as secondary to the veteran's service-connected bilateral foot disorder, is denied. 5. Entitlement to an increased rating greater than 30 percent for a bilateral foot disorder, is denied. ANDREW J. MULLEN Member, Board of Veterans' Appeals