Citation Nr: 0001978 Decision Date: 01/25/00 Archive Date: 02/02/00 DOCKET NO. 98-12 008 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 2. Entitlement to an increased initial evaluation for cold injury residuals, right foot, evaluated as 10 percent disabling, in combination with service-connected left foot disability, from July 23, 1997 to January 12, 1998, and evaluated separately as 20 percent disabling thereafter. 3. Entitlement to an increased initial evaluation for cold injury residuals, left foot, evaluated as 10 percent disabling, in combination with service-connected right foot disability, from July 23, 1997 to January 12, 1998, and evaluated separately as 20 percent disabling thereafter. 4. Entitlement to an initial compensable evaluation for irritable bowel syndrome. 5. Entitlement to service connection for dysentery. 6. Entitlement to service connection for arthritis, right shoulder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Tresa M. Schlecht, Counsel INTRODUCTION The veteran had active service from January 1943 to November 1945. He was a prisoner of war in Germany from June 1944 to May 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. By a January 1998 rating decision, the RO granted service connection for irritable bowel syndrome, and assigned an initial noncompensable evaluation. The RO denied claims of entitlement to service connection for dysentery and arthritis, right shoulder. Service connection was granted for residuals of a cold injury to the right foot and for residuals of a cold injury to the left foot, and a 10 percent evaluation was assigned for the bilateral cold injury residuals from July 23, 1997 to January 12, 1998; a 10 percent evaluation for right foot disability and a 10 percent evaluation for left foot disability thereafter. The January 1998 rating decision also denied entitlement to an increased evaluation in excess of 10 percent for a service-connected anxiety disorder. Thereafter, a rating decision issued in February 1999 increased the assigned initial disability evaluation, after January 12, 1998, for right foot residuals of a cold injury to 20 percent, and increased the assigned disability evaluation for left foot residuals of a cold injury to 20 percent for that same time period, and recharacterized the service-connected acquired psychiatric disability as post- traumatic stress disorder (PTSD). That disability was evaluated as 50 percent disabling. By a rating decision issued in May 1999, the veteran was granted a total disability evaluation based on individual unemployability (TDIU). While a total schedular evaluation for a service-connected disability makes a claim for TDIU moot, under the terms of applicable VA regulations, a grant of TDIU benefits does not moot claims of entitlement to increased evaluations, and the claims for increased evaluations remain before the Board. 38 C.F.R. § 4.16; see Green v. Brown, 11 Vet. App. 472, 476 (1998) (veteran with 100% schedular rating for service-connected disability is not eligible for TDIU evaluation). By a rating decision issued in October 1999, service connection for tinnitus and for bilateral hearing loss was granted. There is no evidence that the veteran has appealed any aspect of that rating decision. No issue regarding the grant of service connection for tinnitus or bilateral hearing loss is before the Board at this time. The issues on appeal are more accurately stated as recharacterized by the Board on the title page of this decision. FINDINGS OF FACT 1. The veteran's service-connected PTSD is manifested by flattened or tense affect, sleep disturbances averaging approximately two to three times weekly, rage episodes, painful memories and intrusive thoughts, diminished peer relationships, and a recent Global Assessment of Functioning (GAF) score of 50. 2. The residuals of a service-connected cold injury to the right foot and to the left foot are manifested by paresthesia in each foot at the distal portion, by pain in each foot, worse in cold weather and at night, and by color change bilaterally. 3. The veteran's irritable bowel syndrome is manifested by recent weight loss and by episodic symptoms like symptoms of dumping syndrome. 4. There is no medical evidence that the veteran currently suffers residuals of dysentery. 5. There is no medical evidence that the veteran, who is a former prisoner of war, has traumatic arthritis of the right shoulder. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 50 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code 9411 (1999). 2. The criteria for an initial 30 percent evaluation for bilateral residuals of a cold injury to the feet, from July 23, 1997 to January 12, 1998, are met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.104, Diagnostic Code 7122 (1997). 3. The criteria for an increased initial evaluation in excess of 20 percent for residuals of a cold injury, right foot, or in excess of 20 percent for residuals of a cold injury, left foot, after January 12, 1998, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.104, Diagnostic Code 7122 (1999). 4. The criteria for a compensable initial evaluation for irritable bowl syndrome are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.114, Diagnostic Code 7319 (1999). 5. The veteran has not submitted a well-grounded claim of entitlement to service connection for dysentery. 38 U.S.C.A. § 5107(a) (West 1991). 6. The veteran has not submitted a well-grounded claim of entitlement to service connection for osteoarthritis of the right shoulder. 38 U.S.C.A. §§ 1101, 1110, 1112, 1154, 5107(a) (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran maintains that his PTSD is more severely disabling than the current 50 percent evaluation reflects. He also asserts that his other service-connected disabilities, especially his cold injury residuals, are more disabling that the current evaluations reflect. He also contends that he is entitled to service connection for dysentery and right shoulder arthritis. I. Claims for Increased Evaluations As an initial matter, the Board notes that an allegation that a service-connected disorder has become more severe is sufficient to well-ground a claim for increase. Proscelle v. Derwinski, 2 Vet. App. 629, 631-32 (1992). The veteran's claim for an increased evaluation for PTSD is plausible, capable of substantiation, and therefore well-grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). The veteran's contentions as to the propriety of the initial evaluations of his service-connected cold injuries and irritable bowel syndrome also present well-grounded claims. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board is satisfied that all relevant facts have been properly developed and that no further assistance to the veteran is required in order to comply with the duty to assist. It is noted in this regard that the veteran was afforded VA examinations. Disability evaluations are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where, however, an appeal arises from an initial rating decision which established service connection and assigned the initial disability evaluation, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). 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. § 4.7. A. Claim for Increased Initial Evaluation for PTSD By a rating decision issued in December 1983, the veteran was granted service connection for a psychoneurosis with obsessional features and depressive and anxiety episodes. That disability was evaluated as 10 percent disabling, under Diagnostic Code 9400, effective from August 1983. By a claim submitted in July 1997, the veteran submitted a claim for "s[ervice]c[onnection] for anxiety-PTSD." On VA examination conducted in September 1997, a generalized anxiety disorder was diagnosed, and a GAF score of 60 was assigned. At that time the examiner noted that the veteran was neat, clean, pleasant, and cooperative, but his affect was flattened. He expressed bitterness about his POW experiences, and related that, after service, he would have uncontrollable rages. He stated that the rages led to the break-up of his marriage, after 25 years, in 1972. He also reported that he left employment because of conflicts with others. He reported that he maintained contact with his four children, lived alone, and had minimal social life. VA outpatient treatment records dated in April and May 1998 reflect that the veteran was being treated for PTSD. May 1998 VA records disclose a diagnosis of severe PTSD. The physician concluded that, as a result of his POW experiences, the veteran had unresolved rage which was manifested by uncontrollable rage reactions which "cost him a very good job with the railroad" and which brought about the end of his marriage in 1972. The examiner noted that the veteran had ongoing sleep disturbances, nightmares, and painful memories and intrusive thoughts while awake. On VA examination conducted in January 1999, the veteran was neat, clean, cooperative, and displayed good judgment, but his affect was tense. The veteran lived alone. He reported that he left a good job with the railroad in 1972. After that, he worked in sales, and sold various things. He stopped working as a salesman after age 65, then drove a cab, and terminated that employment at about age 69. He reported minimal social life. The examiner concluded that the veteran had "considerably diminished" peer relationships. The veteran reported sleep disturbances about two times weekly, and recurring nightmares. He reported occasional difficulty controlling his temper. The examiner assigned a GAF of 50, and noted that the veteran had marked incapacity. At a personal hearing conducted in June 1998, the veteran testified that he had anxiety attacks, including when asleep, which would cause him to wake up nervous and scared, usually several times a week. He testified that he continued to have rage episodes, although he thought the number of these rage episodes was going down as he got older. The veteran's PTSD has been evaluated as 50 percent disabling under 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999). Under the criteria in effect when the veteran filed his claim, a 50 percent disability evaluation is warranted where PTSD is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted with evidence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation requires total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication, persistent delusions or hallucinations, or persistent danger of hurting self or others. 38 C.F.R. § 4.130. The evidence establishes that the veteran has panic attacks more than once weekly, so as to meet the criteria for a 50 percent evaluation. However, the evidence shows that the veteran's panic attacks are episodic and are not "near- continuous" so as to meet, or so frequent as to approximate, the criteria for a 70 percent evaluation. The evidence establishes that the veteran has some depression, but it is not so severe as to impair his ability to appear for or cooperate with VA examinations or clinical treatment. The veteran is clearly able to function independently. There is no evidence that the veteran's speech has ever been illogical, obscure or irrelevant. The Board notes that there is no medical evidence that the veteran has ever displayed such severe symptoms as suicidal ideation, delusions, hallucinations, or inability to perform activities of daily living. The veteran continues to function independently. Although he describes himself as not being social, he is nevertheless able to attend church, and he keeps in contact with his children. These facts are inconsistent with a 70 percent schedular evaluation. The evidence establishes that the veteran's GAF scores have varied from 60, in 1997, to 50 in early 1999. A GAF score of 51 to 60 indicates both moderate symptoms and moderate difficulty in social and occupational functioning. See AMERICAN PSYCHIATRIC ASSOCIATION: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 46-47 (4th ed. 1994); Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). A GAF score of 41-50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. While a GAF score of 50 is classified within the category of "serious" symptoms, that score is on the borderline of the next higher range, representing moderate impairment. In this case, the Board finds that the veteran's disability picture overall is most consistent with a moderate disability picture, so as to warrant a 50 percent evaluation, but does not approximate the criteria for a 70 percent evaluation. The veteran meets one of the revised criteria for a 70 percent evaluation, in that he has unprovoked irritability with periods of violence. However, the Board notes the veteran's testimony that he believes the episodes of uncontrollable rage are decreasing as he gets older. Nevertheless, the Board finds that the veteran meets this criteria for a 70 percent evaluation. Even though the veteran meets at least one criteria for a 70 percent evaluation, the Board finds that his disability picture overall is more consistent with a 50 percent evaluation, particularly in light of his ability to be present at social events and to interact appropriately, his ability to function independently, and the fact that his judgment and insight remain good. The veteran receives regular outpatient treatment, at times participating in a group for POW's as often as weekly, but he has not required hospitalization for treatment of PTSD. The evidence establishes that, during his working years, the veteran took a lower-paying job, at least in part because of his POW experiences. However, the veteran continued to work for more than 20 years after leaving that employment. The evidence establishes that the veteran held gainful employment for more than 40 years after his service discharge. The veteran, who is more than 70 years old, is now retired. However, the evidence is not consistent with severe occupational impairment prior to the veteran's retirement, nor does the evidence reflect that, if the veteran attempted to now obtain employment, his PTSD would preclude him from obtaining or retaining gainful employment. The Board further notes that some of the veteran's employment, in particular, as a salesman, required considerable interaction with others. Nevertheless, the veteran was able to pursue this type of employment for many years. In particular, the Board notes that the veteran himself testified that he quit working as a cab driver because he did not want to work more than 40 hours per week, not because he was unable to interact with potential passengers. Thus, while the evidence establishes that the veteran has difficulty establishing and maintaining relationships, such that peer relationships are "considerably diminished," consistent with a 50 percent evaluation, nevertheless, the evidence contradicts a finding that there is inability to establish and maintain effective relationships. The preponderance of the evidence supports assignment of a 50 percent rating. The Board does not find that the evidence is in equipoise to warrant a more favorable evaluation for any time period. The provisions of 38 U.S.C.A. § 5107(b) regarding reasonable doubt are thus not applicable to warrant a more favorable result. B. Increased Initial Evaluation, Cold Injury Residuals, Right Foot and Left Foot The official evidence of record confirms that the veteran was held as a POW for approximately 11 months, and that the conditions of his internment were consistent with incurrence of cold injuries. On VA examination conducted in September 1997, the veteran had normal gait. He was able to stand, squat, and to supinate and pronate his feet. There was no edema. There were diffuse paresthesias in the distal portion of each foot, bilaterally. A right calcaneal spur was present on radiologic examination. At a personal hearing conducted in November 1998, the veteran testified that he had a lot of pain in his feet when his feet were cold and at night when he went to bed. On VA examination conducted in January 1999, the veteran complained of pain in both feet, worse at night and in cold weather. The veteran's feet were cold to palpitation, pale in color, and the pulses were hard to palpate. There were no findings of osteoporosis, subarticular punched out lesions, or osteoarthritis of either foot on radiologic examination, although there was a plantar spur on the os calcis of one foot. The examiner noted that the veteran used analgesics to relieve pain due to frostbite residuals with some frequency. The examiner concluded that the veteran had considerable, symptomatic residuals of frostbite. By a rating decision issued in January 1998, the veteran was granted service connection for residuals of a cold injury to the feet, bilaterally, and that bilateral disability was evaluated as 10 percent disabling under 38 C.F.R. § 4.104, Diagnostic Code 7122 (1997). Under the criteria of Diagnostic Code 7122 in effect when the veteran filed his claim, prior to January 12, 1998, mild symptoms of a cold injury or chilblains warranted a 10 percent evaluation if unilateral, and the same evaluation, a 10 percent evaluation, if bilateral. With persistent moderate swelling, tenderness, redness, etc., bilateral symptoms warranted a 30 percent evaluation. With loss of toes, or parts, and persistent severe symptoms, unilateral cold injury residuals warranted a 30 percent evaluation; bilateral severe residuals warranted a 50 percent evaluation. By regulatory amendments effective January 12, 1998, the schedular criteria for evaluating cold injury residuals were revised. See 62 Fed. Reg. 65,07 (Dec. 11, 1997). The revised rating criteria for cold injury residuals under Diagnostic Code (DC) 7122 provide, for unilateral injury, a 10 percent evaluation with pain, numbness, cold sensitivity, or arthralgia, or a 20 percent evaluation with pain, numbness, cold sensitivity, or arthralgia plus tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or X-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis) of affected parts. Each affected part, in this case the left foot and the right foot, is to be evaluated separately, and the ratings combined in accordance with 38 C.F.R. §§ 4.25 and 4.26. The Board also notes that Diagnostic Code 7122 was again revised, effective in August 1998, to reflect that the covered disability was residuals of "cold injury" rather than residuals of "frozen feet," but that change is not relevant to this claim. Since the regulations were changed during the pendency of this appeal, the veteran is entitled to have applied whichever set of regulations provide him with the higher rating--at least after the January 1998 effective date of the new regulations. See Rhodan v. West, 12 Vet. App. 55, 57 (1998) (stating that the effective date rule established by 38 U.S.C.A. § 5110(g) prohibits the application of any liberalizing rule to a claim prior to the effective date of such law or regulation); Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). 1. Rating Under Old Criteria, Prior to January 12, 1998 The Board finds that the evidence overall establishes that the veteran's cold injury residuals have been stable during the entire period of the claim and appeal. The Board finds that the veteran's complaints of foot pain, together with objective evidence of neurologic abnormalities (parasthesias), are sufficient to meet the criteria for a 30 percent evaluation for cold injury residuals under the "old" criteria. In particular, the Board notes that, although no swelling, tenderness, or redness were found on medical examination, the criteria for the 30 percent evaluation are not limited to those particular symptoms, since the rating code includes the term "etc." after the listed symptoms. Thus, an increased evaluation to 30 percent is warranted under the old criteria, when the pain described by the veteran at his personal hearing is considered with the objective evidence of neurologic findings on VA examinations for cold injury residuals. However, an evaluation in excess of 30 percent cannot be granted under the pre-1998 criteria, as the rating criteria did not provide a higher evaluation at that time if the disability was bilateral. Under the old criteria, a 50 percent evaluation was available only where there were bilateral severe residuals. While the evidence establishes that the veteran has bilateral, symptomatic cold injury residuals, the evidence does not establish that the residuals have been severe at any time during the period of this initial evaluation. In particular, the Board finds that the evidence that the veteran was able to stand and squat, had a normal gait, and was able to pronate and supinate his foot, and had no areas of tissue loss, is contradictory to a finding that severe residuals were present. 2. Rating under New Criteria, from January 12, 1998 At the time of the January 1999 VA examination, the veteran complained of pain in both feet. Additionally, the medical evidence noted abnormal sensations (paresthesia) were present in both feet, as well as cold sensitivity. Additionally, the examiner described the veteran's feet as pale in color. The examiner did not specifically state whether this paleness was a color change associated with the veteran's cold injury. Resolving reasonable doubt in the veteran's favor, the Board determines that this finding is relevant to the cold injury. Resolving this doubt in the veteran's favor, these findings meet the criteria for a 20 percent evaluation, which requires a finding of arthralgia or other pain or cold sensitivity together with other symptoms such as color changes or tissue loss. Under the revised criteria, in effect as of January 12, 1998, each affected body part may be evaluated separately. Thus, under the revised rating criteria, the veteran is entitled to a 20 percent evaluation for the cold injury residuals in the right foot, since the right foot findings meet the criteria for the 20 percent evaluation. Additionally, the veteran is entitled to a 20 percent evaluation for the cold injury residuals in the left foot, since the left foot findings meet the criteria for the 20 percent evaluation. However, the revised criteria for a 30 percent evaluation require evidence of two of the following symptoms: tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or osteoporosis, punched-out lesions, or osteoarthritis. Radiologic examinations are devoid of any findings of osteoporosis, punched-out lesions, or osteoarthritis. There is no medical evidence that the veteran has tissue loss, nail abnormalities, locally impaired sensation, or hyperhidrosis, nor has the veteran stated or testified that he has such symptoms. The preponderance of the evidence is against a finding that the veteran's cold injury residuals meet the criteria for an evaluation in excess of 20 percent in either the left foot or in the right foot. C. Increased (Compensable) Initial Evaluation for Irritable Bowel Syndrome Service medical records and post-service VA clinical records associated with the claims file are negative for complaints of, findings of, or treatment of, irritable bowel syndrome. On VA examination conducted in September 1997, the veteran complained of intermittent cramping after eating, and he noted that there were times when he would dump the entire contents of his intestinal tracts within a short time after eating. There were no complaints of melena or hematochezia or nausea or loss of appetite. His weight was 150 pounds, hemoglobin and hematocrit were 15.1 and 46. The physician concluded that the veteran was not anemic or malnourished. A diagnosis of irritable bowel syndrome was assigned. At a personal hearing conducted in November 1998, the veteran testified that his weight had recently decreased by nearly 20 pounds for no apparent reason. The veteran expressed a belief that the weight loss was due to his abdominal symptoms. Under the criteria for irritable bowel syndrome, a 10 percent rating is assigned for a moderate degree of disability with frequent episodes of bowel disturbance with abdominal distress. The next higher evaluation, a 30 percent rating, may be assigned for a severe disability with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319 (1999). The evidence reflects that the veteran has recurring episodes of a dumping-type syndrome, with abdominal cramping and liquid stool, but the veteran's desorption of these episodes as occurring about once weekly, on the average, is not equivalent to "frequent" episodes, so as to meet the criteria for a 10 percent evaluation. The veteran describes having liquid stools, but there is no evidence that the dumping-type episodes have resulted in incontinence, inability to eat certain foods, anemia, or malnutrition. Without such evidence, the Board finds that the evidence does not establish "moderate disability" resulting from an intestinal disturbance, so as to meet the criteria for an initial compensable evaluation. The veteran did indicate he believed a drop in weight was associated with the dumping-type episodes. However, the veteran also testified that he was taking a variety of medications, including medication to lower cholesterol, and that some of these medications tasted bad. The veteran also noted that he had had a decrease in appetite. However, he did not indicate that any health care provider had told him that either his weight loss or his decreased appetite were related to intestinal disturbances or to his dumping syndrome-type episodes. The evidence establishes that the veteran has no medical expertise to provide competent medical evidence relating weight loss or other symptoms to his service-connected irritable bowel syndrome. See Epps v. Gober, 126 F.3d 1464, 1468-70 (Fed. Cir. 1997); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992) (lay witness not competent to offer evidence that requires medical knowledge). Since the medical evidence is devoid of reference to any such association, the Board finds that it is not reasonable to assign a compensable evaluation for those symptoms. II. Claims for Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Additionally, if a condition noted during service is not determined to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Furthermore, a disability which is proximately due to, or results from, another disease or injury for which service connection has been granted shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). When aggravation of a disease or injury is proximately due to, or is the result of, a service-connected condition, service connection may be granted, and the veteran shall be compensated for the degree of disability, and no more, over and above the degree of disability existing prior to the aggravation. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The threshold question that must be answered in this case, however, is whether the veteran has presented well-grounded claims for service connection. A well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. The veteran has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that each of his claims is well grounded. 38 U.S.C.A. § 5107(a); Grivois v. Brown, 6 Vet. App. 136, 140 (1994); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). When a veteran has presented a well-grounded claim within the meaning of 38 U.S.C.A. § 5107(a), VA has a duty to assist the veteran in the development of his claim. 38 U.S.C.A. § 5107(a). In general, a veteran must satisfy three elements for a claim for service connection to be well-grounded. First, there must be competent evidence of a current disability (a medical diagnosis). Second, there must be evidence of incurrence or aggravation of a disease or injury in service, as shown through lay or medical evidence. Lastly, there must be evidence of a nexus or relationship between the in-service injury or disease and the current disorder, as shown through medical evidence. See Epps v. Gober, 126 F.3d 1464, 1468 (1997). Additionally, special presumptions are applicable as to former prisoners of war for certain diseases. The veteran was held as a prisoner of war of the German government from June 1944 to May 1945. Where a veteran is: (1) a former prisoner of war, and (2) as such was interned or detained for not less than 30 days, certain chronic diseases, such as post-traumatic osteoarthritis, shall be service connected if manifest to a degree of 10 percent or more at any time after discharge or release from active military, naval, or air service even though there is no record of such disease during service. See 38 C.F.R. §§ 3.307, 3.309(e). The Board further notes that in cases in which the veteran engaged in combat with the enemy during a period of war, satisfactory lay evidence will be accepted as sufficient proof of service-connection of any disease or injury alleged to have been incurred, if consistent with the circumstances, conditions or hardships of such service. See 38 U.S.C.A. § 1154(b). A. Service Connection for Dysentery In this case, no residuals of dysentery were noted in the veteran's service medical records. No residuals of dysentery, other than irritable bowel syndrome, have been diagnosed since the veteran's service, at any time. The veteran's statements that he had dysentery while a POW are credible and consistent with the evidence of record. However, there is no medical evidence or opinion that the veteran currently has dysentery, or any residuals thereof, other than irritable bowel syndrome (IBS), for which, as noted above, the veteran has been awarded service connection. The laws authorizing veterans' benefits provide benefits only where there is current disability. In the absence of evidence a current medical diagnosis of dysentery, service connection may not be granted for that disorder. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). As noted above, to the extent that the veteran's irritable bowel syndrome is a residual of dysentery, service connection has been granted for that disability, and service connection cannot be separately granted for dysentery without evidence that the veteran has current disability due to that disorder. The veteran has been notified that a current medical diagnosis of dysentery is needed, along with medical evidence showing that he has current disability (other than irritable bowel syndrome) due to that disorder, to establish a well-grounded claim. Robinette v. Brown, 8 Vet. App. 69 (1995). B. Service Connection for Arthritis, Right Shoulder The veteran maintains that his current arthritis of the right shoulder was caused by the conditions of his POW experience, in particular, sleeping on hard surfaces, without bedding. Alternatively, the veteran testified, at a personal hearing conducted in June 1998, that his right shoulder was injured when he landed after parachuting from his airplane. While the record shows that the veteran has been diagnosed with mild degenerative arthritic changes of both shoulders bilaterally, no evidence has been submitted indicating that he suffers from traumatic arthritis of either shoulder. While the Board notes that service connection for traumatic arthritis is warranted for a former POW if shown to be present to a degree of 10 percent or more anytime after discharge, no diagnosis of traumatic arthritis of the right shoulder is contained in the record. The Court has specifically held that the diagnosis of other types of arthritis does not give rise to the presumption. See Mullins v. Derwinski, 2 Vet. App. 522 (1992). Consequently, service connection can only be established by medical evidence showing that the veteran's degenerative arthritis was either incurred in service or resulted from another disease or injury for which service connection has been established. However, the evidence associated with the record is devoid of any medical evidence relating the veteran's right shoulder arthritis to an injury incurred when the veteran parachuted from his airplane or to his internment as a POW. Accordingly, the Board finds that the nexus requirement for establishing a well-grounded claim may not be satisfied by reliance on the regulatory presumption for a former POW, since degenerative arthritis is not listed as a disease specific to a former POW. Similarly, the veteran must provide medical evidence linking in-service injury incurred in combat (parachute jump injury) to a current disorder, as the provisions of 38 U.S.C.A. § 1154 do not satisfy the requirement of medical evidence linking the combat injury to a present disorder. The veteran has not submitted such evidence. Kessel v. West, 13 Vet. App. 9 (1999). In the absence of medical evidence of a disability which may be presumed service-connected when incurred by a former POW, and in the absence of medical evidence of a nexus between an injury allegedly incurred in combat, the veteran has not established a well-grounded claim of entitlement to service connection for arthritis of the right shoulder. See Epps, 126 F.3d at 1468-1470. The veteran has been informed that such evidence is required. There is no further duty to assist in development of the claim. The claim must be denied. ORDER Entitlement to an evaluation in excess of 50 percent for PTSD is denied. Entitlement to a 30 percent initial evaluation for bilateral cold injury residuals, right foot and left foot, from July 23, 1997 to January 12, 1998, is granted. An increased initial evaluation in excess of 20 percent for cold injury residuals, left foot, after January 12, 1998, is denied. An increased initial evaluation in excess of 20 percent for cold injury residuals, right foot, after January 12, 1998, is denied. An initial compensable evaluation for irritable bowel syndrome is denied. Entitlement to service connection for dysentery is denied. Entitlement to service connection for arthritis, right shoulder, is denied. WARREN W. RICE, JR. Member, Board of Veterans' Appeals