Citation Nr: 0001187 Decision Date: 01/13/00 Archive Date: 01/27/00 DOCKET NO. 96-45 491A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an increased rating for low back syndrome with lumbar scoliosis, currently rated as 10 percent disabling. 2. Entitlement to an increased rating for residuals of a left elbow injury to include any left ulnar neuropathy and cubital tunnel syndrome, currently rated as zero percent disabling. 3. Entitlement to service connection for bilateral flexible pes planus (flat feet) with bilateral posterior tibial tendinosis. 4. Entitlement to service connection for a bilateral knee condition. 5. Entitlement to service connection for memory loss. 6. Entitlement to service connection for tension/rebound headaches also diagnosed as probable migraine headaches. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Fetty, Associate Counsel INTRODUCTION The veteran's DD-214 reflects that he served on active duty from August 1975 to November 1994 and that he also had over two years and nine month's of prior active service. He served in the Persian Gulf during 1990 and 1991. According to the veteran's DD-214, he served as a Transportation Services Sergeant. He received the Southwest Asia Service Medal, Bronze Service Star, Kuwait Liberation Medal, Meritorious Service Medal, Army Commendation Medal (7th award), Army Achievement Medal, Good Conduct Medal (7th award), National Defense Service Medal (2nd award), Armed Forces Expeditionary Medal, NCO Professional Development Ribbon (Number 3), Army Service Ribbon, Overseas Service Ribbon (Number 3), Driver and Mechanic Badge with Bar, Drill Sergeant Identification Badge, and the Overseas Service Bar. He did not receive any medals that conclusively establish participation in combat. This appeal arises from an April 1996 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee that, inter alia, denied increased ratings for low back syndrome with lumbar scoliosis and for residuals of a left elbow injury to include any left ulnar neuropathy and cubital tunnel syndrome. The veteran has appealed to the Board of Veterans' Appeals (Board) for favorable resolution of the matter. In September 1996, the case was transferred to the Columbia, South Carolina RO where denial of the requested benefits was continued in a January 1997 rating decision. In May 1997, the veteran testified before an RO hearing officer. In October 1998, the veteran indicated that he did not desire a hearing before a traveling member of the Board. In January 1999, the Board decided an issue on appeal and remanded the remaining increased rating claims for further development. The requested development has been completed to the extent possible. During the remand period, the veteran perfected an appeal of a June 1998 RO rating decision that determined that the claims for service connection for bilateral pes planus with bilateral posterior tendinosis, for a bilateral knee condition, for memory loss, and for tension/rebound headaches were not well grounded. The Board will therefore address those issues also. The veteran has not requested a hearing concerning those claims. In April 1996 and January 1997 rating decisions, the RO denied a claim for service connection for abdominal pain/stomach disorder, inter alia and properly notified the veteran of those determinations and his appeal rights. He timely appealed some of the issues, but not the denial of service connection for abdominal pain/stomach disorder. In June 1999, the veteran submitted a notice of disagreement (NOD) as to the denial of service connection for abdominal pain/stomach disorder. The NOD was untimely with respect to that issue and therefore the Board lacks jurisdiction to address that issue. See 38 U.S.C.A. § 7105(b)(1) (West 1991); 38 C.F.R. § 20.302 (1999). In a July 1999 rating decision, the RO again denied service connection for the claimed stomach disorder. The veteran has not expressed dissatisfaction with that decision and he is reminded that if he desires to appeal that decision, he must submit a NOD within one year of the date of mailing that rating decision. FINDINGS OF FACT 1. All development necessary for an equitable disposition of the increased rating issues addressed herein has been completed. 2. The veteran's service-connected low back syndrome with lumbar scoliosis is manifested by marked limitation of forward bending in the standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space. 3. Additional impairment due to radiculopathy and lower extremity weakness approximates the criteria for severe lumbosacral strain. 4. Impairment that is equivalent to pronounced intervertebral disc syndrome with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of diseased disc with little intermittent relief is not shown. 5. The left ulnar neuropathy is manifested by subjective complaints of pain and tingling from the arm to the fingers, arm and hand numbness, and left elbow tenderness resulting in moderate incomplete paralysis. 6. Neither severe incomplete paralysis nor complete paralysis (Griffin claw deformity) of the left arm is shown. 7. The veteran did not serve in combat but he did serve in Southwest Asia during the Persian Gulf War period. 8. A medical diagnosis of bilateral flexible pes planus with bilateral posterior tibial tendinosis has been given. 9. The veteran has not submitted medical evidence tending to link bilateral flexible pes planus with bilateral posterior tibial tendinosis to any disease or injury in service nor has he submitted lay evidence of a nexus between foot or ankle pain and active service in Southwest Asia during the Persian Gulf War period. 10. There is no competent medical evidence tending to show that degenerative changes of the feet were present in service, became manifest within any applicable presumptive period, or that they are otherwise related to active service. 11. The veteran has not submitted medical evidence tending to link complaint of knee pain to any disease or injury in service nor has he submitted lay evidence of a nexus between knee pain and active service in Southwest Asia during the Persian Gulf War period. 12. The veteran has not submitted objective evidence that any claimed memory loss is or has been at least 10 percent disabling at any time or that it is otherwise related to active service in any way. 13. The veteran's tension/rebound headaches, also diagnosed as probable migraine headaches, are related to active service. CONCLUSIONS OF LAW 1. The criteria for a 40 percent evaluation for low back syndrome with lumbar scoliosis are met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5292, 5293, 5295 (1999). 2. The criteria for a 20 percent evaluation for left ulnar neuropathy, cubital tunnel syndrome are met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8516 (1999). 3. The claims for service-connection for bilateral flexible pes planus with bilateral posterior tibial tendinosis, for bilateral knee pain, and for memory loss are not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. Tension/rebound headaches, also diagnosed as probable migraine headaches, were incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 1137, 5107 (West 1991); 38 C.F.R. § 3.303 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a preliminary matter, the Board finds that the veteran's increased rating claims are plausible and capable of substantiation and are therefore well grounded within the meaning of 38 U.S.C.A. § 5107(a). A claim that a service- connected condition has become more severe is well grounded where the claimant asserts that a higher rating is justified due to an increase in severity. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 631-632 (1992). The Board also is satisfied that all relevant facts have been properly developed and no further assistance to the veteran is required in order to comply with the duty to assist. Id. Disability evaluations are determined by comparing pertinent symptomatology to the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. See 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (1999). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. See 38 C.F.R. § 4.3 (1999). The veteran's entire history is reviewed when making disability evaluations. See 38 C.F.R. 4.1 (1999); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). However, the current level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (1999); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). I. Increased Rating for the Low Back The veteran's October 1972 enlistment examination report reflects that he had no prior relevant medical problems. In March 1993, the veteran reported back pain with physical activity for three to four weeks and use of Motrin. Lumbosacral strain was assessed. A November 1993 X-ray showed mild degenerative disk narrowing at L4-5. A December 1993 report notes continued low back pain despite an exercise program, a corset, and medication. A 50 percent decrease in range of motion of the spine in all planes was reported. Lower extremity strength was 4/5 with bilateral guarding. Straight leg raising was positive at 45 degrees. The assessment was chronic low back pain with disk problem to be ruled out. A May 1994 report notes continued back problems due to probable degenerative joint disease. A P3 profile was recommended as the veteran was already on a P2 (no running) profile. The diagnosis was degenerative joint disease of the lumbar spine with radiation. A December 1994 VA general medical examination report notes complaint of chronic low back pain, among others. No left elbow complaint was noted. Musculoskeletal examination revealed full range of motion of all joints with no bone or joint abnormality noted. Straight leg raising was negative, bilaterally. All other systems were essentially normal and the diagnoses included complaint of chronic low back pain. There were also other findings not related to this appeal. A December 1994 VA joints examination report notes a history of low back pain. During the examination, the veteran reported a history of multiple in service back injuries from falls during physical training. He reported constant back pain that was worse with bending over or lifting heavy objects. His reported treatment had included non-steroidal medication, muscle relaxants, physical therapy, and a lumbosacral corset with some relief provided by each. The veteran denied radiculopathy, bowel, or bladder complaints. Back tenderness was noted but no spasm was elicited. He also reported left elbow "funny-bone" problems with dysesthesia down into the left, non-dominant, hand. The examiner found normal posture and normal feet. The left elbow had no swelling or deformity. Palpation of the medial or lateral epicondyle was painless. Tinel's test at the cubital tunnel was positive. Range of motion of the left elbow was from zero degrees of extension to 140 degrees of flexion. Pronation and supination was normal. Compression of the ulnar nerve at the elbow produced dysesthesia at the ulnar aspect of the left hand. Spinal examination showed no postural abnormality of fixed deformity. The veteran wore a lumbosacral corset. There was tenderness at the midline of the lumbosacral junction but no spasm. Straight leg raising was weakly positive on the right with pain and tingling in the calf at 70 degrees. The left leg was negative and the neurologic examination was otherwise normal. The lumbar spine flexed forward to 70 degrees, backward to 30 degrees, 40 degrees of right and left flexion and rotation. Deep tendon reflexes were 2+ and symmetric at the knee and 1+ and symmetric at the ankle. A December 1994 VA X-ray showed mild scoliosis of the upper lumbar spine with convexity to the right. There was a small bone spur at the anterosuperior aspect of he L5 vertebral body. Much of the spinous process of the L5 vertebra was absent; thought possibly to be the result of developmental conditions. X-rays of the left elbow were negative. The relevant impressions were mild to moderate left elbow cubital tunnel syndrome and mechanical low back pain/chronic lumbar strain with some possible mild S1 radiculopathy on the right side. A February 1995 VA Persian Gulf examination report notes complaint of back pain that did not radiate. It had been noticed for the previous three years. A February 1995 VA X- ray showed minimal spurring at the superior endplate of L5. In a March 1995 rating decision, the RO established service connection for low back syndrome, lumbar scoliosis and assigned a 10 percent rating under Diagnostic Code 5295. The RO also established service connection for mild ulnar neuropathy, cubital tunnel and assigned a noncompensable rating under Diagnostic Code 8516. An August 1995 VA general medical examination report notes that the veteran reported chronic low back pain and left ulnar nerve palsy. The examiner reported marked tenderness to palpation of the left ulnar nerve at the elbow but normal distal reflexes and sensation. Musculoskeletal examination indicated full range of motion of all joints with no bony or joint abnormality appreciated. A VA form dated in August 1995 indicates that the veteran received a metal back brace and a left elbow brace. A September 1995 VA physical therapy report indicates complaint of low back pain with paresthesia radiating into the right lower extremity on flexion of the right extremity or the spine. The symptoms were partially relived by a corset. A differential diagnosis of possible spina bifida versus herniated nucleus pulposus/disc bulge was offered. A computerized tomography (CT) study was recommended. In October 1995, a lumbar spine CT report notes mild disc bulging at L4-5 without evidence of disc herniation. Diffuse disc bulging was evident at L5-S1 as well as a possible disc herniation abutting the right nerve root. Spina bifid occulta was noted at L5 and partially at S1. In an April 1996 rating decision, the RO continued a 10 percent rating for the low back disorder and continued a noncompensable rating for the left elbow disorder. In May 1997, the veteran testified before an RO hearing officer that he had terminated his employment with the Post Office about a month earlier. He indicated that he drove a truck, as opposed to carrying mail, and reported that his back caused problems climbing into and out of his truck. He testified that he currently took college courses but felt throbbing back pain after sitting 45 minutes. He described the back pain as aching that went to the toes. He testified that he performed therapeutic exercises and walked but that these activities caused increased back pain. He also said that his TENS unit helped. He reported that his back brace forced him to assume better posture while seated, which tended to help and that any lifting caused increased pain. He reported that standing longer than five minutes caused increased pain. He produced his medication containers and read the names Tylenol, Flexeril, and Salsalate from them. At the hearing, the veteran also submitted VA clinical reports dated in 1997. A May 1997 VA outpatient treatment report notes complaint of low back pain. Flexeril was prescribed. In June 1997, the RO received additional VA clinical reports that note treatment for several health problems. A May 1996 electromyography (EMG) report notes normal right lower extremity study. A June 1997 VA neurological examination report indicates that the veteran wore a transcutaneous electrical nerve stimulation (TENS) unit with electrodes to the lumbosacral region. He complained of pain and weakness. He had good muscle functions of the hip flexors, quadriceps, and hamstrings. He could stand on his heels and toes without difficulty. Pinprick examination of the lower extremities revealed no abnormality. A June 1997 VA spine examination report indicates that the veteran reported an in-service back injury from falling from a truck. He reported bilateral leg pain, worse on the right, with some shooting pain and numbness in the toes. He currently took Motrin and muscle relaxants plus two other medications. He reported that he alternated use of two back braces, a hard one and a softer one, and that he used a TENS unit. He had no bladder or bowel dysfunction. He said that his back hurt worse than the legs. He reported ongoing VA physical therapy. The examiner reported that the veteran currently could forward flex to 30 degrees at which point he had pain in his back. He could extend only to neutral. He had difficulty cooperating with lateral bending but he did bend to 20 degrees in each direction without pain. Reflexes at the knees and ankles were 2+ bilaterally. Sensation to light touch and to pinprick was intact. He had motor weakness on the right and left with 4/5 strength in the tested muscle groups. Straight leg raising was negative in the seated position but positive at 20 degrees in the supine position. The veteran walked with a markedly slow gait and shortened steps when leaving the examination room. The relative assessment was "no concrete physical findings of radiculopathy." The examiner noted that the veteran's reported symptoms appeared to be out of proportion to the physical findings. The examiner also reported that the veteran displayed positive Waddell signs indicating factitious or non-organic radicular findings. Current X-rays showed mild degenerative changes at the lower lumbar spine, most prominent at the L4-5 level. Some minimal changes since February 1995 were shown. Spina bifida occulta at L5, not considered clinically significant, was also shown. The remainder of the lumbar spine was negative. A March 1998 VA joints examination report notes findings for knee and ankle joint conditions. A March 1998 VA neurological examination report notes complaint of back pain and use of pain relievers. The veteran's muscle mass, tone, and strength were found to be normal. Sensory examination was normal. In January 1999, the Board remanded the issue of an increased rating for low back syndrome with lumbar scoliosis to the RO for additional development. The Board requested that the recent VA examiner provide an addendum estimating the degree of back disability that could be attributed to the service- connected low back syndrome, lumbar scoliosis, degenerative changes, and disc pathology. In February 1999, the RO requested that the veteran report any recent treatment for his back. In June 1999, the veteran submitted various VA clinical reports that chiefly concerned the left elbow. A June 1999 VA examination report notes that the veteran reportedly fell from a trailer in 1997 but that his back symptoms preceded that fall. The examiner noted a review of the claims file. The examiner noted that the veteran wore a back corset and a TENS unit and reported that the veteran had three positive Waddell signs, including pain with rotation, pain with axial loading, and also increased somatization, particularly over the lumbar area. Lumbar range of motion was to 40 degrees of flexion and to 10 degrees of extension. Straight leg raising was negative to 60 degrees bilaterally. The veteran could squat and return to standing. He could stand on his tiptoes and heels. Motor strength on manual testing was 3/5 to 4/5 in the bilateral iliopsoas, quadriceps, hamstrings, tibialis anterior, gastrocs, and the extensor hallucis longus. No sensory dermatomes were noted; however, the veteran did complain of numbness in the left lateral dorsum, which did not follow a dermatomal pattern. Deep tendon reflexes were 2+ at the patellae, the knees, and at the Achilles tendons. The examiner felt that the veteran's complaints of pain were far out of proportion to his physical findings. The examiner reported that it was unclear whether the 1997 injury exacerbated his symptoms. The Board notes at the outset of its legal analysis that the case was recently remanded so that the VA examiner could provide the Board with an estimate of disability due to service-connected back problems (low back syndrome, lumbar scoliosis, degenerative changes, and disc pathology). The Board felt that this estimate would be helpful in accurately determining the true level of disability caused by service- connected symptomatology. On remand, the examiner reported that the complaints of pain on spine rotation, axial loading, and other lumbar area pain were out of proportion. However, the examiner did not estimate to what extent the veteran's complaints were out of proportion nor did the examiner offer any explanation of why the veteran's complaints were felt to be out of proportion to the clinical findings. The examiner did not mention any disc pathology. The Board is therefore uncertain whether to exclude any of the veteran's complaints of painful motion, weakness, and neurological deficits and resolves any remaining doubt on this issue in favor of the veteran. A review of the above facts indicates limitation of flexion to 40 degrees and limitation of extension to 10 degrees. Lateral bending and rotational movement was painful at any position. Additional muscle weakness is noted in the bilateral iliopsoas, quadriceps, hamstrings, tibialis anterior, gastrocs, and the extensor hallucis longus. There was also complaint of numbness in the left lateral dorsum. Straight leg raising was positive at 20 degrees in the supine position. A 1995-CT study revealed mild disc bulging at L4-5 without evidence of disc herniation and diffuse disc bulging was evident at L5-S1 as well as a possible disc herniation abutting the right nerve root. Disc narrowing at L4-5 has been shown by X-rays since November 1993. As noted above, the veteran's low back syndrome with lumbar scoliosis is currently rated 10 percent disabling under Diagnostic Code 5295, which is the diagnostic code for lumbosacral strain. Under the provisions of that code, a 10 percent rating is warranted when the symptoms are limited to characteristic pain on motion. Diagnostic Code 5295 provides that a 20 percent evaluation is warranted when there is muscle spasm on extreme forward bending and loss of lateral spine motion, unilateral, in the standing position. A 40 percent evaluation is warranted for severe lumbosacral strain manifested by listing of the whole spine to the opposite side, positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space. A 40 percent evaluation is also warranted if only some of these manifestations are present if there is also abnormal mobility on forced motion. See 38 C.F.R. § 4.71a, Code 5295 (1999). The medical evidence of record clearly indicates that the lumbar spine disability is more severe than reflected in the current rating for characteristic pain on motion. The veteran had only 30 degrees of forward flexion in 1997 and 40 degrees in 1999. Given these symptoms, the Board finds that there is marked limitation of forward bending in the standing position. The objective evidence also shows loss of lateral motion with osteoarthritic changes or narrowing or irregularity of joint space. Some radiculopathy is also suggested. Taking these symptoms into account as well as the tenets of 38 C.F.R. §§ 4.40, 4.45, 4.59, and DeLuca, supra, the Board finds that overall the service-connected back symptoms produce impairment approximating the maximum (40 percent) rating offered for severe lumbosacral strain. As the criteria for a 40 percent rating under Diagnostic Code 5295 are met, the claim for an increased rating must therefore be granted. Turning to other potentially available diagnostic codes, the Board notes that Diagnostic Code 5292, under which limitation of motion of the lumbar spine is rated, does not offer a rating higher than 40 percent. Therefore, although potentially applicable to this case, use of this code would not result in a greater advantage to the veteran. Diagnostic Code 5293 offers a higher (60 percent) rating for intervertebral disc syndrome; however, to warrant a 60 percent rating, the symptoms or overall impairment must be equivalent to persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of diseased disc with little intermittent relief. In this case, some radicular findings are present as evidenced by a positive straight leg-raising test in the supine position and complaint of numbness in the leg. The medical evidence, however, shows ample deep tendon reflexes and also shows that there is no muscle spasm. For this reason, the Board does not find that the criteria for pronounced intervertebral disc syndrome are met, even considering any additional impairment due to weakness, fatigability, or incoordination. II. Increased Rating for Residuals of a Left Elbow Injury. The veteran's service medical records reflect a left elbow injury in August 1990. Complaint of elbow pain persisted and a November 1993 report indicates a diagnosis of left olecranon bursitis. During a December 1994 VA general medical examination, the veteran reportedly did not mention an elbow complaint. The examiner noted full range of motion of all joints and no neurologic disorders. During a December 1994 VA joints examination, the veteran reported a history of problems with the left elbow "funny- bone." He said that he noticed occasional dysesthesia (distortion of sensation, Dorland's Illustrated Medical Dictionary 515 (28th ed. 1994)) down the left arm to the left, non-dominant, hand. The examiner reported that the left elbow had no swelling or deformity. There was no pain on palpation of the medial or lateral epicondyle. The veteran did display a positive Tinel's sign (tingling sensation at the distal end of a limb when percussion is made over the site of a divided nerve, Dorland's Illustrated Medical Dictionary 1527 (28th ed. 1994)) at the cubital tunnel. Flexion of the elbow was from 0 to 140 degrees with normal pronation and supination. There were dyesthesias into the ulnar aspect of the left hand during compression of the ulnar nerve at the elbow. The relevant diagnosis was cubital tunnel syndrome, left elbow, mild to moderate. X-rays of the left elbow were negative. In a March 1995 rating decision, the RO established service connection for mild ulnar neuropathy, cubital tunnel (left arm), and assigned a noncompensable rating under Diagnostic Code 8516 on the basis that less than mild incomplete paralysis had been shown. An August 1995 VA general medical examination report reflects marked tenderness on palpation of the ulnar nerve of the left elbow with normal distal sensation and reflexes. The relevant diagnosis was left ulnar nerve palsy, by patient report. In September 1995, the left elbow was reevaluated and was found to be painful at the proximal ulna. The veteran was not able to support the elbow on an armrest and he reported reduced range of motion due to discomfort. Bursitis was assessed. In an April 1996 rating decision, the RO continued a noncompensable rating for the left elbow disorder and the veteran appealed. An April 1996 VA treatment report indicates status post surgery for the left cubital tunnel syndrome with constant pain despite NSAIDS (non-steroidal antiinflammatory drugs). In November 1996, the veteran reported that he was receiving physical therapy and that his doctor told him that he would have to live with the elbow injury. In May 1997, the veteran testified before an RO hearing officer that he felt a tingling sensation extending to the fingers when he rested his left elbow on hard surfaces. He testified that extending the left fingers caused some pain in the back of the elbow due to a broken part of the bone. He testified that he also had some left arm pain and weakness also. He indicated that his right arm was his dominant arm. A June 1997 VA examination report indicates that the veteran tucked his left arm close to the chest in a demonstration of pain during the examination. He was reluctant to move the arm stating that the arm muscles tightened up. He was able, with coaxing, to show function in all muscles. The examiner reported that there was no weakness of left-hand grip or other abnormality of muscle mass or tone. Sensory examination showed left arm diffuse numbness throughout without regard to anatomical pattern for peripheral nerve or nerve root. The examiner noted that the decreased pinprick numbness transcended the ulnar, median, and radial nerves. Biceps and triceps muscles were good despite the veteran's report that arm pain limited his ability to use those muscles. The impression was no evidence of neurologic lesion or ulnar neuropathy. A March 1998 VA joints examination report does not note any relevant left elbow findings. In January 1999, the Board remanded the case to the RO for additional development including any clinical records of left elbow treatment and post surgery therapy reports since April 1996. In a February 1999 letter to the veteran, the RO requested that he report any pertinent left elbow treatment since April 1996. In April 1999, the RO received additional VA clinical reports dated from 1996 to 1999; however, the reports were negative for any pertinent information. In June 1999, the veteran submitted additional clinical reports. Among these is an August 1995 VA request for a left elbow brace. An October 1995 VA report notes left elbow treatment in an effort to reduce left elbow pain. A June 1999 VA joints examination report did not address the left elbow. Initially, the Board takes note of the April 1996 VA report indicating status post left elbow surgery with reports of constant left arm pain. After remanding the issue for an additional search for information concerning this surgery, no further information has been uncovered. The Board therefore finds that the duty to assist the veteran in developing this issue has been fulfilled. The above facts indicate that the veteran's left ulnar neuropathy is manifested by subjective complaints of pain and tingling down the arm to the fingers. Some left arm and hand numbness is also shown by decreased sensation to pinprick. Neurologic lesion, ulnar neuropathy, muscle weakness, or limitation of motion of the left arm is not demonstrated by objective medical evidence. As noted above, the veteran's left (minor side) ulnar neuropathy, cubital tunnel syndrome is currently noncompensably rated under Diagnostic Code 8516. In rating the minor side, the code provides a 10 percent rating for mild incomplete paralysis; a 20 percent rating for moderate incomplete paralysis; a 30 percent rating for severe incomplete paralysis; and a 50 percent rating for complete paralysis (Griffin claw deformity) of the ulnar nerve. The code further provides that when the involvement is wholly sensory, the assigned rating should be for the "mild," or at most, the "moderate" degree. See 38 C.F.R. § 4.124a, Diagnostic Code 8516 (1999). Comparing the provisions of the rating schedule to the current symptoms, the Board finds that indeed the criteria for at least a 10 percent rating for "mild" incomplete paralysis are met, as the veteran's symptoms are wholly sensory. However, the rating schedule also permits the assignment of a 20 percent rating where sensory involvement is to a "moderate" degree. In considering whether the symptoms indicate a "moderate" degree of impairment, the Board notes that the veteran has also complained of left arm pain and left elbow tenderness. Although the complaints of pain and tenderness are mostly subjective, the recent VA examiner did note that the veteran was guarding the left arm during the examination. Resolving any reasonable doubt in favor of the veteran, the Board also finds that the criteria for a 20 percent rating for "moderate" incomplete paralysis are met. The next higher (40 percent) rating under Diagnostic Code 8516 is not warranted unless the medical evidence shows "severe" incomplete paralysis. Impairment to that extent is clearly not met or approximated in this case. Consideration has been given to other potentially available diagnostic codes that provide higher ratings; however, because impairment due to such disorders as muscle damage, weakness or limitation of motion is not shown, it would appear that evaluation of this disability under any other potentially available diagnostic code is inappropriate. The above rating determinations are based upon consideration of applicable provisions of the rating schedule. Additionally, however, there is no showing that the veteran's service-connected low back syndrome with lumbar scoliosis and left elbow disability reflect so exceptional or so unusual a disability picture as to warrant the assignment of any higher evaluation (than assigned herein) on an extra-schedular basis. In this regard, the Board notes that neither the veteran's service-connected low back syndrome nor his left elbow disability has been objectively shown to markedly interfere with employment (i.e., beyond that contemplated in the assigned ratings). The Board emphasizes that the assignment of a 40 percent evaluation for severe lumbosacral strain and a 20 percent evaluation for the left elbow contemplates some interference with employment; interference beyond that, however, simply is not shown with respect to either disability. Moreover, neither disability is shown to warrant frequent periods of hospitalization or to otherwise render impractical the application of the regular schedular standards. In the absence of evidence of such factors as those noted above, the Board is not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 157, 158-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). III. Service Connection Claims A. Factual Background The veteran's service medical records are largely negative for the claimed disorders (bilateral pes planus with posterior tibial tendinosis, a bilateral knee condition, memory loss, and tension/rebound headaches also diagnosed as probable migraine headaches). These service medical records note a long history of sinus congestion and related problems and a November 1993 allergy clinic report notes complaint of headaches that frequently occurred over the forehead. The service medical records contain no mention of any complaint or treatment of pes planus, tendinosis, knee conditions, or memory loss. In the veteran's original claim for service connection submitted in December 1994, he mentioned such disorders as fallen arches, chondromalacia of both knees, and memory loss since 1990. A December 1994 VA general medical examination report notes several complaints, including athlete's foot and memory loss. Full range of motion of all joints was reported. The examiner noted that there was no evidence of pathology, other than tinea pedis, and that all other complaints including memory loss were subjective only. A December 1994 VA nose and sinus examination report notes sinus surgery in 1986 followed by the return of bifrontal headaches. The headaches occurred two to three times per week and were somewhat relieved by aspirin or Tylenol. The report also notes that the veteran had a history of allergies. An examination of the nasal structures was essentially negative and the impression was chronic sinusitis with allergic rhinitis. The examiner did not address the headaches. A December 1994 joints examination report does not mention any foot or knee complaint except for a history of dry flaky skin of the feet. The examiner noted that the feet had a normal posture with no Achilles tendonitis or plantar fasciitis. A February 1995 VA Persian Gulf War examination report notes complaint of knee and ankle pain when walking. The veteran also reported that since he returned from the Persian Gulf, he had daily headaches, which were generalized. A VA consultation sheet dated in February 1995 reflects that the VA Persian Gulf examiner requested a CT study of the head because of the veteran's complaint of headaches. In March 1995, a VA CT brain scan showed no abnormalities. In April 1995, VA X-rays showed normal knees. A VA mental health clinic report dated in April 1995 indicates headaches since returning from the Persian Gulf. The examiner noted that there was no psychiatric pathology. The impression was adjustment reaction. No diagnosis was given. Another April 1995 report notes complaint of severe headaches since return from the war. A July 1995 VA neurology consultation report notes a history of headaches predating duty in the Persian Gulf but since that time they had become constant. The examiner noted that the previous head CT was negative and that there were no other relative findings. The examiner felt that the headaches were probable tension headaches and prescribed Elavil. No diagnosis was given. In August 1995, another VA examiner saw the veteran and offered an assessment of history of tension headaches. In July 1995, the veteran requested service connection for claimed head, stomach, and joint problems, possibly stemming from active service in the Persian Gulf. A VA general medical examination report dated in August 1995 contains diagnoses of chronic headaches, diffuse arthralgias, and chronic abdominal pain, among others. In an April 1996 rating decision, the RO denied claims for service connection for headaches, joint pain of knees and ankles, abdominal pain/stomach disorder, and memory loss due to undiagnosed illness. The rating decision notes that none of the claimed conditions was noted in the veteran's service medical records or within two years of leaving the Persian Gulf. In a January 1997 rating decision, the RO continued denial of service connection for headaches, memory loss, knee and ankle pain, and abdominal/stomach pain due to an undiagnosed illness. VA clinical reports received in May 1997 note that in May 1997, the veteran reported that his headaches were preceded by an aura. He reported that he had always had headaches during his lifetime and that his sisters suffered from migraines. The assessment was migraine versus vascular headaches. A neurology consultation was scheduled for June 1997. A June 1997 VA neurology examination report notes complaints and findings relative to the left elbow and to the low back. It does not mention headaches or memory loss. A March 1998 VA joints examination report notes complaint of bilateral knee and ankle pain. During the examination, the veteran denied a history of trauma to the knees or ankles but he did mention that pain in the knees and ankles began in 1985 and had become progressively worse since that time. He reported use of Motrin for pain relief with some success and that he had also received steroid injections in the knees, with temporary relief. He reported that he could currently walk about 500 yards before knee pain forced him to stop. The examiner noted that the veteran walked with a reciprocating heel toe gait with no evidence of antalgia. He displayed a weak heel rise bilaterally with varus at the hind part of the foot. Flexion of the ankles was essentially normal. There was tenderness at the tibialis posterior tendon. The knees showed full range of motion. The examiner reported bilateral knee flexion to 120 degrees and extension to 0 degrees. The examiner offered impressions of bilateral pes planus secondary to posterior tibial tendinosis and normal knees. X-rays of the knees were negative. X-rays of the feet showed minimal degenerative changes of both feet. An April 1998 VA neurological examination report notes that the veteran had not complained of any memory disturbance during three previous neurology consultations nor during the current examination. The examiner noted that the veteran currently reported headaches. The veteran indicated that he was currently enrolled in college and was making satisfactory academic progress. He reported that he took headache medication daily and pain relievers daily. The examiner reported that the veteran was alert with no sign of organic mental dysfunction. Motor and sensory modalities were normal. The examiner noted that the veteran's claims file contained documented tension headaches but felt that a major component could be "drug rebound headache" given the medications prescribed. The examiner noted that there was no evidence of memory loss. In a June 1998 rating decision, the RO found that claims for service connection for bilateral pes planus with bilateral posterior tibialis tendinosis, a bilateral knee condition, memory loss, and tension/rebound headaches were not well grounded. In April 1999, the RO received additional VA outpatient reports dated from 1996 to 1999. These reports note that in June 1997 an examiner recorded that the veteran had reported a history of headaches since adolescence but worse since Saudi Arabia. Family history of migraine headaches was noted and the examiner offered a diagnosis of "headaches, probably migraine." In September 1997, a VA examiner noted headaches for 7 to 8 years. The headaches were described as sharp pain in the forehead occurring during the day or night. The veteran reported that they might last from one minute to one day and they occurred three to four times per week. There were also complaints of dizziness, blurred vision, and occasional nausea. The examiner recorded a family history of severe headaches and noted that the veteran denied any drug use or smoking. The examiner reported that the neurology examination was unremarkable and reported that there was "no known precipitating factors." The assessment was probable combined tension-type headaches plus migraine. The examiner felt that sinusitis was another possible cause of the headaches. In June 1999, the veteran submitted a notice of disagreement (NOD) indicating dissatisfaction with the RO's rating decision of June 1998. The veteran reported that during a recent examination for bilateral posterior tibial tendinosis, the doctor told him that there was something wrong with his feet but that the doctor might have failed to include it in his report. The veteran reported that he told his doctor that he still had bilateral knee pain as well as pain in various other joints. He reported continued memory loss. He mentioned continued stomach disorders and continued headaches that he felt were not due to tension/rebound. He requested further medical examination. In June 1999, the veteran submitted copies of VA medical records; however, these concern other claims and do not address pes planus, tendinosis, the knees, memory loss, and tension/rebound headaches. A June 1999 VA joints examination report notes that the veteran could squat to near full squatting and resume standing. He could stand on his tiptoes and his heels. There was no other information in the report that was pertinent to the service connection claims. B. Legal Analysis In order to establish service connection for a disability, the evidence must show it resulted from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110, 1131, 1137 (West 1991); 38 C.F.R. § 3.303 (1999). A chronic disease will be considered to have been incurred in service when manifested to a degree of 10 percent or more within 1 year from the date of separation from active service. See 38 C.F.R. § 3.307 (1999). Degenerative arthritis shall be considered a chronic disease within the meaning of 38 C.F.R. § 3.307. See 38 C.F.R. § 3.309 (1999). Service connection may be granted for any disease first noted after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (1999). In the case of a combat veteran who alleges that a disease or injury is service connected, the burden of the veteran who seeks benefits for an allegedly service-connected disease or injury and who alleges that the disease or injury was incurred in or aggravated by combat service is lightened by 38 U.S.C.A. § 1154(b). See Collette v. Brown, 82 F.3d 389 (1996). However, the veteran has not claimed, and the record does not otherwise indicate, that the veteran served in combat during service. The Board finds that the veteran did not serve in combat and that the provisions of 38 U.S.C.A. § 1154(b) therefore do not apply. Because the record establishes that the veteran did serve in Southwest Asia during the Persian Gulf War period, the regulation concerning service connection for certain undiagnosed illnesses should be mentioned briefly. Except as otherwise provided, VA shall pay compensation to a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of this Section, provided that such disability: (i) Became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2001; and (ii) By history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. (2) For purposes of this Section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, nonmedical indicators that are capable of independent verification. (3) For purposes of this Section, disabilities that have existed for 6-months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 U.S.C.A. § 1117 (West Supp 1999); 38 C.F.R. § 3.317(a)(1999). Signs or symptoms which may be manifestations of undiagnosed illnesses include, but are not limited to: (1) Fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) sign or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and, (13) menstrual disorders. 38 C.F.R. § 3.317(b) (1999). Compensation shall not be paid under this section if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War or if there was affirmative evidence of a supervening condition or if the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c) (1999). The threshold legal question with respect to any claim for service connection is whether the veteran has met his initial burden of submitting evidence to show that the claim is well- grounded, meaning plausible. See 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In the absence of a well-grounded claim, there is no duty to assist the claimant in developing the facts pertinent to the claim, and the claim must fail. See Slater v. Brown, 9 Vet. App. 240, 243 (1996); Gregory v. Brown, 8 Vet. App. 563, 568 (1996) (en banc); Grivois v. Brown, 6 Vet. App. 136, 140 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The veteran must generally satisfy three elements for each 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 (medical evidence or, in some circumstances, lay evidence). Last, there must be evidence of a nexus or relationship between the in-service injury or disease and the current disorder, as shown by medical evidence. See Epps v. Gober, 126 F.3d 1464, 1468 (1997). The nexus requirement may be satisfied by evidence that a chronic disease subject to presumptive service connection manifested itself to a compensable degree within the prescribed period. See Traut v. Brown, 6 Vet. App. 495, 497 (1994); Goodsell v. Brown, 5 Vet. App. 36, 43 (1993). In the alternative, the chronicity provisions of 38 C.F.R. § 3.303(b) are applicable where the evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumption period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded on the basis of 38 C.F.R. § 3.303(b) if the condition is observed during service or during any applicable presumption period, if continuity is demonstrated thereafter, and if competent evidence relates the present condition to that symptomatology. See Savage v. Gober, 10 Vet. App. 488, 498 (1997). The Board notes that special provisions with respect to well- groundedness apply to service connection claims arising from active service in Southwest Asia during the Persian Gulf War period. According to VAOPGCPREC 04-99, a well grounded service connection claim under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 requires some evidence of the following four elements: Active service in Southwest Asia during the Persian Gulf War period; manifestations of one or more signs or symptoms of undiagnosed illness; objective indications of chronic disability of 10 percent of more during the specified period; and lastly, a nexus between the chronic disability and the undiagnosed illness. VAOPGCPREC 04-99 further explains that evidence that the illness is "undiagnosed" may consist of evidence that the illness cannot be attributed to any known diagnosis, or, at a minimum, that the illness has not been attributed to a known diagnosis by physicians providing treatment or examination. The manifestations may be established by lay evidence if the evidence pertains to signs or symptoms ordinarily susceptible to identification by lay persons. The veteran's own testimony may also establish that the illness is chronic. Lay evidence may also be sufficient to establish a nexus between the chronic disability and the undiagnosed illness where that nexus is capable of lay observation. In this case, the diagnosis of bilateral flexible pes planus with bilateral tibial tendinosis was not given until March 1998, many years after active service. The Board finds that no medical evidence of a nexus between the diagnosed condition and an incident of active service has been submitted. Noting that X-rays first showed degenerative changes of the feet in March 1998, the Board also finds that competent medical evidence tending to show that degenerative changes of the feet were present in service or became manifest within any applicable presumptive period has not been submitted. Although the veteran has asserted that there is a connection between active service and his bilateral foot disorders, the veteran, as a layman cannot supply an etiology of a medical condition. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). In this regard, the Board emphasizes that a well-grounded claim must be supported by competent evidence, not merely allegations. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The claim may still be well grounded on the basis of 38 C.F.R. § 3.303(b) if the bilateral foot condition is observed during service or during any applicable presumption period, if continuity is demonstrated thereafter, and if competent evidence relates the present condition to that symptomatology. Savage, 10 Vet. App. at 498. The veteran has asserted continuity of symptomatology; however, to well ground the claim, he must still submit competent evidence of a relationship between the present condition and that symptomatology. With respect to the standard for well groundedness set forth in VAOPGCPREC 04-99, the Board notes that a diagnosis of bilateral flexible pes planus secondary to bilateral posterior tibial tendinosis was made in March 1998. Because a diagnosis has been rendered, it cannot be said that the disorder "by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis." Therefore the provision for well groundedness under VAOPGCPREC 04-99 have not been met. The Board notes that the veteran has also reported ankle pain and that no diagnosis has been given that clearly accounts for the ankle pain. As such, 38 C.F.R. § 3.317 might be for application for an undiagnosed illness manifested by ankle pain; however, the veteran reported that he has felt this ankle pain since 1985. This is affirmative evidence that an undiagnosed illness manifested by ankle pain was not incurred during active service in the Southwest Asia Theater of Operations during the Persian Gulf War. As such, the veteran must submit competent medical evidence relating inservice ankle pain symptoms to well ground the claim. Because no such medical evidence has been submitted, the claim for service connection for bilateral pes planus or any other foot or ankle pain is not well grounded. With respect to the claim for service connection for a bilateral knee condition, the facts indicate that the veteran reported that knee pain began during active service in 1985 and became progressively worse over time. Service medical records are negative for any abnormality of either knee. Within a month of separation from active service, the veteran had reported chondromalacia of the knees. Since that time, the medical evidence submitted has failed to identify any pathology of either knee, although the veteran's complaints of knee pain have persisted. The lack of a current diagnosis concerning either knee necessarily renders the claim not well grounded under the legal standard of Epps, supra. Additionally, the claim fails to meet the well groundedness standard of VAOPGCPREC 04-99 because no nexus evidence (lay or medical) has been provided linking the knee pain to active Persian Gulf service. Indeed, the veteran himself reported that the knee pain began in 1985. Accordingly and similar to the analysis above, the Board finds that the kind of evidence necessary to well ground this claim has not been submitted. The claim for service connection for bilateral knee pain must be denied as not well grounded. Concerning the claim for service connection for memory loss, the Board notes that the service medical records are negative for the claimed disorder and no diagnosis has been rendered. Even though the veteran first reported the condition to VA within the presumption period for organic disease of the nervous system and for psychosis, a medical opinion linking memory loss to a current psychiatric or nervous system disorder is needed to meet the well groundedness standard cited in Epps, supra. The claim fails to meet the well groundedness standard of VAOPGCPREC 04-99 because a recent examiner noted that the veteran did not have memory loss. The Board must therefore find that the claim lacks objective evidence of a chronic disability caused by memory loss that is at least 10 percent or more disabling during the specified period. The claim for service connection for memory loss must therefore be denied as not well grounded. Because the claims for service connection for bilateral pes planus with tibial tendinosis, bilateral knee pain, and for memory loss are not well grounded, VA is under no duty to assist in developing the facts pertinent to these claims. See Epps, 126 F.3d at 1468. Furthermore, the Board is aware of no circumstances in this matter that would put VA on notice that any additional relevant evidence may exist which, if obtained, would well-ground the claims for service connection. See McKnight v. Gober, 131 F.3d 1483, 1485 (Fed. Cir. 1997). The Board views its discussion above as sufficient to inform the veteran of the elements necessary to submit a well-grounded service connection claim and the reasons why these three service connection claims are inadequate. See Robinette v Brown, 8 Vet. App. 69, 77-78 (1995). Concerning the claim for service connection for tension/rebound headaches, the Board notes that in a January 1999 Board decision, "frequent painful headaches" were found to be manifestations of the veteran's service-connected sinusitis. As such, the recent claim for service connection for tension/rebound headaches will address headaches resulting from other etiology. A diagnosis of "chronic headaches" was given during an August 1995 VA general medical examination. In June 1997, a diagnosis of "headaches, probably migraine" was given (the Board will consider this a diagnosis of probable migraine headache). At other times, clinical assessments included migraine versus vascular headache, tension plus migraine headache, and drug rebound headache. One medical examiner found that the headaches were related to prescription medication taken, at least in part, for service-connected disabilities. Another examiner felt that the headaches were the result of service-connected sinusitis. The Board finds no reason to doubt these opinions and again notes that some headaches are considered to be part of the veteran's sinusitis disability. However, concerning the diagnosis of probable migraine headache, the Board finds that this represents an additional disability. The evidence indicates that the veteran has persistently reported an increase in his headache symptomatology since returning from the Persian Gulf, that an additional diagnosis concerning probable migraine headaches was rendered, and that various etiologies have been offered, some of which tend to link the headaches to active service. The Board also notes that there is no medical evidence that tends to specifically exclude the veteran's active service as a possible cause of the probable migraines. Considering the above, the Board is still quite uncertain as to whether the evidence favors the claim. However, certainty is not the legal standard for granting claims. Resolving reasonable doubt on the matter in favor of the veteran, the Board finds that the evidence favors the claim for service connection for tension/rebound headaches also diagnosed as probable migraine headaches. ORDER Subject to the laws and regulations governing the payment of monetary benefits, a 40 percent evaluation for the service- connected low back syndrome with lumbar scoliosis granted. Subject to the laws and regulations governing the payment of monetary benefits, a 20 percent evaluation for service- connected moderate incomplete paralysis of the left ulnar nerve with cubital tunnel syndrome is granted. In the absence of evidence of a well-grounded claim, service connection for bilateral flexible pes planus (flat feet) with bilateral posterior tibial tendinosis, for bilateral knee pain, and for memory loss is denied. The claim for service connection for tension/rebound headaches, also diagnosed as probable migraine headaches, is granted. R. E. SMITH Acting Member, Board of Veterans' Appeals