Citation Nr: 0004228 Decision Date: 02/17/00 Archive Date: 02/23/00 DOCKET NO. 94-26 178 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for a disability of the left knee, a disability of the right shoulder, a disability of the right foot, a disability of the right hip, a disability manifested by numbness of the upper and lower extremities, a chronic organic gastrointestinal disability, residuals of venereal disease, and cardiovascular disease, including hypertension. 2. Entitlement to a rating in excess of 10 percent for disability of the left shoulder, in excess of 10 percent for disability of the left elbow, in excess of 10 percent for disability of the left foot, and in excess of 10 percent for disability of the cervical spine. 3. Entitlement to compensable evaluations for hemorrhoids, a kidney disability, and temporomandibular dysfunction (TMJ syndrome). REPRESENTATION Appellant represented by: Jewish War Veterans of the United States ATTORNEY FOR THE BOARD Neil Reiter, Counsel INTRODUCTION The veteran served on active duty from October 1972 to October 1993. This appeal arises from regional office rating actions beginning in March 1994 denying either service connection for multiple claimed disabilities, or increased ratings for multiple recognized disabilities. In this regard, in March 1994, the veteran was granted service connection for residuals of kidney stones, for which a 0 percent evaluation has been assigned. He was also granted service connection for chronic prostatitis, for which a 10 percent evaluation has been assigned, and for urethral stricture, for which a 0 percent evaluation has been assigned. However, the statement of the case and subsequent supplemental statements of the case have retained the issue of service connection for a kidney disability. The veteran has not indicated in any correspondence the nature of any further genitourinary disability that he wants service connected. Since service connection is already in place for a kidney disability, residuals of kidney stones, and in view of the Board decision to remand the issue of an increased rating for the residuals of the kidney stones and the question of service connection for residuals of venereal disease, the Board has concluded that there is no remaining issue of service connection for a kidney disability for review in the present appeal. In addition, the claims file indicates that the veteran appealed the initial decision by the regional office in March 1994 denying a compensable evaluation for disability of the cervical spine. On his appeal in September 1995, the veteran stated that this disability should be rated at the minimum of 10 percent "for slight limitation or higher." Subsequently, in a rating in April 1996, the regional office granted a 10 percent for disability of the cervical spine. In the reasoning expressed in a supplemental statement of the case in April 1996, the regional office indicated that they considered the rating of 10 percent for disability of the cervical spine to be a complete grant of the benefit sought by the veteran in his letter in September 1995. However, the Board considers the veteran's letter of September 1995 to be ambiguous. It can be read as indicating that he desired a minimum rating of 10 percent, but did not exclude a higher rating for this disability. Resolving the doubt in his favor the Board will retain, and consider, this disability as an appellate issue. Finally, in his appeal in June 1994, the veteran expressly indicated that he desired to withdraw his appeal for service connection for a claimed seizure disorder. This issue is therefore not before the Board at this time. FINDINGS OF FACT 1. Aside from the issues being remanded, the regional office has obtained all relevant evidence necessary for an equitable disposition of the recognized appellate issues. 2. While the veteran had complaints of numbness in the upper and lower extremities during and after service, objectively, various clinical studies during and after service have failed to diagnose a separate and distinct chronic disability manifested by numbness of the upper and lower extremities. 3. While the veteran had gastrointestinal complaints during and after service, various clinical studies during and after service have failed to objectively confirm the presence of an organic gastrointestinal disability. 4. A chronic disability of the right hip or right shoulder was not present in service, and a chronic disability of the right hip and right shoulder have not been demonstrated after discharge from service. 5. A chronic disability of the left knee which reasonably can be presumed to have had its inception in service is present. 6. The veteran was treated for venereal disease, urethritis, and stricture of the urethra in service, and he has been granted service connection for residuals of a stricture of the urethra and prostatitis. 7. The veteran was treated for complaints of chest pain and hypertension with medication for a few years during service. Thereafter, his blood pressure readings were both normal and elevated during the remainder of his service. 8. The blood pressure reading on examination for discharge from service in July 1993 was 130/90, and a Department of Veterans Affairs (VA) echocardiogram in April 1997 showed some slight valvular regurgitation. 9. The veteran was treated for complaints of bilateral foot pain during and after service, with various diagnoses being offered. 10. The veteran's claims for service connection for residuals of venereal disease, cardiovascular disease, including hypertension, and a disability of the right foot are plausible. 11. The veteran's left foot disability, residuals of surgical removal of neuromas, is no more than moderately disabling. 1l. The veteran's hemorrhoids are no more than mild to moderately disabling. 12. The veteran has full range of motion of the left elbow, with some pain on motion and X-rays show possible post surgical changes. 13. The veteran has disc disease of the cervical spine that is moderately, but not severely disabling. It is manifested by moderate limitation of motion with no more than moderate resulting functional impairment. 14. The veteran's disability of the left shoulder is manifested by infrequent episodes of shoulder dislocation with guarding of movement at shoulder level. 15. The veteran has TMJ syndrome, but he has a maximum inter-incisal opening of at least 1 3/4 inches (43 millimeters), and some muscle pain and limitation on eating and talking. CONCLUSIONS OF LAW 1. The record does not currently contain evidence which raises well grounded claims for entitlement to service connection for a disability manifested by numbness of the upper and lower extremities, a chronic organic gastrointestinal disability, a chronic disability of the right hip, and a chronic disability of the right shoulder. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (1999). 2. The evidence currently of record establishes the presence of well grounded claims for service connection for residuals of venereal disease, a chronic cardiovascular disability, including hypertension, and a disability of the right foot. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 3. A currently present disability of the left knee can reasonable be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 4. The criteria for a rating in excess of 10 percent for disability of the left elbow and in excess of 10 percent for disability of the left foot have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40-4.42, 4.44, 4.45, 4.57-4.59, Part 4, Diagnostic Codes 5206-5209, 5271, 5284 (1999). 5. The criteria for a compensable evaluation for hemorrhoids have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, Part 4, Diagnostic Code 7336 (1999). 6. The criteria for a rating of 20 percent, but not higher, for disability of the left shoulder; for a 20 percent evaluation, but not higher, for disability of the cervical spine; and for a 10 percent, but not higher, evaluation for TMJ syndrome have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40-4.42, 4.44, 4.45, 4.59, Part 4, Diagnostic Codes 5200-5203, 5287, 5293, 9905 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran maintains, in essence, that service connection should be granted for all of the claimed disabilities because he was treated for such disabilities during service and after discharge from service. He contends that the service medical records document that the claimed disabilities were present in service, and that there is documentation showing the presence of such disabilities after discharge from service. He also maintains that he is entitled to higher evaluations for his various service-connected disabilities. He contends that the TMJ syndrome causes difficulty eating, difficulty talking, and headaches, that he has frequent recurrences of hemorrhoids, that he has significant pain and limitation of motion in the cervical spine, that the pain in the left foot has increased in severity recently, that he has limited motion and function in the left shoulder, and that he has increasing pain in the left elbow. I. Service Connection The threshold question that must be resolved with regard to a claim for service connection is whether the veteran has presented evidence of a well grounded claim. 38 U.S.C.A. § 5107; Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim is a plausible claim that is meritorious on its own or capable of substantiation. Murphy v. Derwinski, supra. An allegation that a disorder is service connected is not sufficient; the veteran must submit evidence in support of the claim that would justify a belief by a fair and impartial individual that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The quality and quantity of the evidence required to meet the statutory burden, of necessity, will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet. App. 91-93 (1993). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the inservice injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, for example, in service, will permit service connection for a disease or disability first shown as a clear-cut clinical entity at some later date. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303. Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. In addition, the U.S. Court of Appeals for Veterans Claims, (the Court) has determined that service connection is in order when aggravation of a veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition. The Court indicated that a veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). IA. Right Shoulder The service medical records show that the veteran was treated for complaints of dislocation of the right shoulder in July 1977. Periodic physical examinations and other service medical records for the next several years are negative for any complaints, findings, or diagnoses indicative of disability of the right shoulder. The veteran did complain of pain and numbness in the upper extremities in the late 1980's and 1990's, but there were no specific complaints or findings relating to the right shoulder. On examination for retirement from service in July 1993, the veteran provided a history of disability relating to the left shoulder, but not the right shoulder. Physical examination was essentially normal for the right shoulder. On a VA general medical examination in February 1994, the veteran had complaints relating to the left shoulder, but not the right shoulder. VA outpatient treatment reports and service facility medical records after service show that the veteran complained of pain in the right shoulder in March and September 1995. Physical examination of the right shoulder at these times was essentially normal, with full range of motion. On VA examinations in May 1996 and April 1997, the veteran complained of pain in the shoulders, especially when he attempted to raise his arms. The physical examination in May 1996 showed a full range of motion of the right shoulder, although with complaints of pain on full motion. The physical examination in April 1997 showed some slight limitation of motion of the right shoulder. An X-ray of the right shoulder was reported normal. An addendum to this 1997 examination in March 1998 indicated that the examiner believed that there was no evidence of current disability of the right shoulder. In service the veteran underwent treatment briefly following his complaint that his right shoulder had popped out in July 1977. However, the evidence demonstrates that this injury resolved with treatment, and was acute and transitory in nature. Thereafter, the service medical records, including periodic examinations and the examination for retirement from service in 1993, failed to show complaints or findings indicative of a chronic disability of the right shoulder. The evidence of record simply does not establish that the veteran incurred a chronic disability of the right shoulder in service. The veteran had complaints of pain in the right shoulder about 1 1/2 years after discharge from service, but physical examination in the outpatient treatment clinics in 1995 failed to show any physical abnormality. While there was some limitation of motion on the VA examination in 1997, an X-ray of the right shoulder was normal, and the examiner, in an addendum in 1998, diagnosed no disability in the right shoulder. Thus, the present record does not establish that the veteran now has an objective, identifiable disability of the right shoulder which can be related to service or the 1977 injury. On appeal, the veteran has maintained that he has a right shoulder disability which was caused by, or is related to the strain resulting from the service-connected disability of the left shoulder, or is related to the injury in 1977. However, when the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to that effect is required. Grottveit v. Brown, supra. In this case, there is no private medical opinion or opinion from a VA physician or service physician indicating that there is any causal or etiological relationship between the veteran's current complaints and any injury in 1977 that occurred to the right shoulder, to the disability in the left shoulder, or to any service connected disability. There is no current medical finding of a chronic disability of the right shoulder which was incurred in service, or a current diagnosis of a disability of the right shoulder. Consequently, the claim for service connection for disability of the right shoulder is not well grounded. IB. Right Hip The service medical records show that the veteran complained of pain in both knees and the hips in September 1984. Physical examination showed full range of motion in the joints. In February 1989, the veteran complained of pain in the right upper and lower leg. In June 1993, the veteran complained of right hip pain. An X-ray of the right hip was normal. The diagnostic impression was mild degenerative joint disease of the right hip. The veteran also complained of pain and numbness in the upper and lower extremities in the late 1980's and early 1990's but there were no specific complaints relating to the right hip. On examination for retirement in July 1993, the veteran indicated that he had a history of arthritis in the right knee and both hips, first noted in 1988, and treated with rest. Physical examination did not show any disability of the right hip. On a VA general medical examination in February 1994, the veteran had no specific complaints involving the right hip. Service department and VA outpatient treatment reports showed that the veteran complained of pain in the lower back radiating into the hip and leg in February 1994. X-rays of the lumbosacral spine showed some abnormality. On a VA examination in May 1996, the veteran stated that he had been diagnosed with arthritis in the hips previously. He complained of occasional stiffness and pain with various activities. On physical examination, there was full range of motion of the hips. There was no evidence of crepitus or tenderness in the hips. X-rays of the hips were reported normal. The diagnosis was no abnormality of the hips bilaterally by X-ray or physical examination. On a VA examination in April 1997, the veteran complained of some aching in the right hip. Physical examination showed some slight limitation of motion in the right hip. The diagnostic impression was arthritis of the hips, by history, and X-rays of the hips were ordered. X-rays of the hips were reported normal. On an addendum in March 1998, the diagnosis was sprain/strain of both hip joints. The service medical records show that the veteran had isolated complaints of pain in the right hip on a few occasions in service. While a diagnosis was made of mild degenerative joint disease of the right hip, X-rays of the right hip were normal. In fact, X-rays of the right hip were also reported normal after discharge from service. As noted by recent examiners, without X-ray evidence of degenerative changes in the right hip, the diagnosis of degenerative joint disease in the right hip cannot be sustained. The service medical records show isolated, or acute and transitory, complaints of pain in the right hip. There was no continuity of symptomatology in service, and no showing that the isolated complaints were connected in a pattern that would demonstrate a chronic disease entity. As previously indicated, X-rays of the right hip failed to demonstrate degenerative changes. Thus, the present record fails to demonstrate that a chronic disability of the right hip was present in service. After discharge from service, the veteran was again seen on one or two occasions with complaints involving the right hip. Again, X-rays of the right hip were negative. While a diagnosis was offered in 1998 suggesting strain or sprain of the right hip, there is no medical evidence showing an etiological relationship between such a diagnosis, first demonstrated a few years after discharge from service, and any disability treated in service. Furthermore, the record simply does not show any diagnosis of a sprain or strain in service. On appeal, the veteran has maintained that he has a right hip disability which is proximately due to or the result of, or is in some manner related to, the disability of his left knee and left foot. However, as previously indicated, where the determinative issue involves a finding of medical causation, or etiology, competent medical evidence to that effect is required. Grottveit v. Brown, supra. The present record fails to demonstrate that there is any medical opinion or medical evidence to establish a causal connection between any present disability of the right hip and any inservice disease or injury, or any service-connected disability. In addition, there is no medical evidence presently of record establishing that the disabilities of the left knee and left foot are aggravating any nonservice-connected right hip disorder. In summary, presently, the record does not establish that a chronic disability of the right hip was present in service, or that a chronic disability of the right hip has been established as being present after discharge from service. If there has been a disability of the right hip present after discharge from service, there is presently no medical evidence establishing a link between any disability of the right hip first shown after discharge from service and any disability treated in service or any service-connected disability. Consequently, the claim for service connection for disability of the right hip is not well grounded. IC. Chronic Gastrointestinal Disability The service medical records show that the veteran had numerous complaints of gastrointestinal distress during service. He received various medications, including Tagamet and Mylanta. X-rays of the stomach in 1985, an upper gastrointestinal series in 1987, an upper gastrointestinal series in January 1992, and an intravenous pyelogram in April 1992 was evaluated as normal. On examination for retirement in July 1993, no gastrointestinal disability was noted or diagnosed. The veteran continued to complain of occasional gastrointestinal distress after discharge from service, as noted by VA and service department outpatient treatment reports. In May 1995, it was suspected that he had reflux esophagitis. On a VA examination in May 1996, the veteran claimed that he had undergone an upper gastrointestinal series in 1986 or 1987, and that an ulcer and "tear" were found. He also recalled that gastroesophageal reflux was diagnosed in service. On the examination in May 1996, he complained of intermittent crampy abdominal pain. He denied weight loss, lack of appetite, or hematemesis. Physical examination of the stomach was essentially normal. An upper gastrointestinal study was suggested. The diagnoses included history of irritable bowel syndrome, history of gastroesophageal reflux disease, and history of peptic ulcer disease. VA outpatient treatment reports show that in November 1996 a colonoscopy examination was normal. On a VA examination in April 1997, the veteran provided a similar history and similar complaints as noted above for the previous VA examination, and physical examination was essentially normal. An upper gastrointestinal series was read as normal. The examiner concluded that there was no evidence of an ulcer, gastroesophageal reflux, or obstruction. While the veteran had varied complaints relating to the gastrointestinal system during service, for which he was treated symptomatically, various physical and clinical examinations, including two upper gastrointestinal series, evaluated his gastrointestinal system as normal. The examination for retirement in July 1993 also did not report any diagnosis of a chronic organic gastrointestinal disability. Thus, the evidence fails to demonstrate the presence of an identifiable, organic disability of the gastrointestinal system during service. The veteran continued to have gastrointestinal complaints after discharge from service. Again, however, clinical studies including a colonoscopy and upper gastrointestinal series, were normal. Specifically, the upper gastrointestinal series in 1997 failed to show the presence of ulcer disease, ulcer craters, or esophageal reflux. While diagnoses were made in service and after service of possible ulcer disease or reflux esophagitis based on the veteran's symptoms, such disabilities were not confirmed by clinical studies. The present record fails to demonstrate the presence of an identifiable, organic, chronic disability of the gastrointestinal system in service or after service. Thus, on the current evidence of record, the claim for service connection for an organic disability of the gastrointestinal system is not well grounded. ID. Numbness of the Upper and Lower Extremities Service medical records show that at various times in late 1989 and early 1990 the veteran complained of pain and numbness in the upper and lower extremities. Various neurological and orthopedic workups were essentially normal, and testing for heavy metal toxicity was negative. A MRI of the brain was negative. In early and mid-1992, the veteran again complained of numbness in the arms. It was noted that an extensive neurological workup in 1989 and early 1990 had been within normal limits. Further neurological examination resulted in the diagnostic impression of thoracic outlet syndrome. An electromyogram on the right upper extremity was normal and an electromyogram on the left upper extremity showed left ulna neuropathy. However, it was believed that there might be some somatization, and further studies, including a vascular surgical consultation, were undertaken and the ultimate conclusion was that there was no thoracic outlet syndrome. A MRI of the cervical spine in November 1992 did show a herniated disc in the cervical spine. Service connection has been established for that disorder; in fact, the rating of that disability is considered below. The veteran's neurological history was noted on the retirement examination in July 1993. On clinical evaluation, there was no neurological disability noted. The veteran was scheduled for further neurological examination in October 1993, during which a MRI of the brain and an electroencephalogram were within normal limits. The neurological examination was within normal limits. On a VA general medical examination in February 1994, the neurological examination was essentially normal. VA outpatient treatment reports and service department outpatient reports indicate that the veteran did complain of neck pain and neuropathy in the upper extremities after service. In August 1995, an electromyogram showed no evidence of cervical radiculopathy. An electromyogram in July 1996 showed no evidence of cervical radiculopathy either. On a VA examination in May 1996, the veteran's history was reviewed. The veteran complained of pain and numbness in the upper extremities. Neurological examination of the upper extremities was described as normal. On a special neurological examination, his history was again reviewed. The neurological examination was essentially normal. The sensory examination was slightly inconsistent. On a VA examination in July 1997, the veteran's medical history was again reviewed. Neurological examination was essentially normal. Sensory examination showed some decreased sensation on the left side of the face, but it did not follow any particular nerve distribution. Thus, the service medical records show that, while the veteran had complaints of numbness and pain in the upper and lower extremities during service, clinical studies failed to establish the presence of an identifiable, chronic, neurological disability. Various clinical tests were interpreted as normal. Neurological examination at the time of discharge from service was also interpreted as normal. The neurological complaints continued after service, but again, the medical records failed to demonstrate the presence of an identifiable organic neurologic disability. Specifically, various examinations failed to show evidence that the neurological complaints were representative of cervical radiculopathy, or any identifiable disease process. In addition, there are no medical opinions or other medical evidence pointing to any etiological relationship between the neurological complaints and any disability treated in service or any service connected disability. In summary, despite extensive medical evaluations for his complaints, the present record fails to establish the presence of an identifiable organic neurological disability in service, or after service. Consequently, the claim for service connection for a neurological disability manifested by numbness in the upper and lower extremities is not well grounded. IE. Left Knee Disability The service medical records show that the veteran was treated in September 1976 for pain and edema in the left knee following a fall. An X-ray of the left knee was negative, and the diagnostic impression was sprain of the left knee. The veteran was seen for complaints of pain in both knees in September 1984. He was again seen for complaints of pain in both knees in May and June 1985 after he bruised both kneecaps. In February 1991, the veteran was treated for complaints involving the left knee and back after he twisted his left knee and back. On the retirement examination in July 1993, the veteran provided a history regarding his right knee, but did not mention his left knee. On February 2, 1994, the veteran was seen at a service department facility for complaints involving a sharp pain in the lower back radiating down the left leg and pain in the left knee of one week's duration. Gait was normal, and X-rays of the lumbosacral spine showed disc degeneration of L5-S1. The diagnostic impression was low back strain. He was referred for orthopedic consultation for the problem with the left knee. On a VA examination on February 9, 1994, the veteran indicated that he had injured his left knee in the past and that a lateral meniscus injury had been suspected. X-rays of the knees showed that the left knee was essentially normal. Outpatient treatment reports in April 1994 indicate that the veteran was seen for complaints of swelling and buckling of the left knee, with pain worse in the last several months when putting weight on the lateral side while sleeping. The veteran reported trauma to the left knee several years previously when he fell. A MRI of the left knee in May 1994 resulted in the diagnosis of meniscus and ligamentous tears. In September 1995, the veteran complained of continued pain and swelling in the left knee, with a history of multiple injuries since 1976. Surgery was recommended. In October 1995, the veteran underwent surgery for repair of the cartilage in the left knee. The veteran had twisting injuries and trauma to the left knee during service, with occasional complaints of bilateral knee pain. The last twisting injury to the left knee occurred in 1991. In early 1994, he again complained of a pain and buckling of the left knee when he complained of back pain. When he was examined by the VA in February 1994, he gave a history of a suspected tear of the left knee meniscus, and this was confirmed by a MRI a few months later. When he was scheduled for surgery in September 1995, his history was significant for multiple injuries since 1976. While there is no specific medical opinion relating the veteran's torn meniscus and disability of the left knee, found shortly after discharge from service, to the complaints and injuries of the left knee noted in service, with reasonable doubt resolved in the veteran's favor, the Board finds that the veteran's disability of the left knee had its inception in service. In essence, it is not possible to determine with any certainty whether any particular injury in service caused or contributed to the disability found after service. The veteran has indicated that he had recurrent pain in the left knee for many years in service. The examiner in September 1995 considered it was significant that the veteran had a history of multiple documented injuries dating to 1976. In essence, the evidence on this issue is in equipoise; with reasonable doubt resolved in his favor, the Board concludes that the veteran's current left knee disability was incurred in service. IF. Right Foot Disability, Residuals of Venereal Disease, Cardiovascular Disability The veteran had complaints of right foot pain and pain in both feet on various occasions during service. The diagnoses included heel spurs, right ingrown toenails, and pain in both feet. On examination for retirement in July 1993, mild pes planus was noted. Various outpatient treatment reports and VA examinations after service indicate that the veteran continued to complain of bilateral foot pain. A podiatrist in June 1994 provided a statement indicating that the veteran had a 13-year history of left foot trauma and bilateral foot pain. It was noted that there were no recent X-rays, and that physical examination showed tenderness to palpation of the plantar fasciae of both feet. VA examinations have shown slightly diminished arches bilaterally and hammertoes bilaterally. While X-rays have not show heel spurs, plantar fasciitis was diagnosed on different occasions. In essence, the veteran has presented a plausible claim for service connection for a right foot disability. While the present record does not contain any medical statement that the veteran's present foot disabilities are etiologically related to the complaints of foot pain noted in service, there is some evidence of a continuity of symptomatology for the complaints that began in service. There is also the finding of pes planus noted for the first time on the retirement examination in July 1993, and the findings of a diminished arch and hammertoes on VA examination soon thereafter. The claim for service connection for a disability of the right foot is at least plausible, and therefore well grounded. The Board will remand this issue (as provided below) for further development. The veteran was treated with medication for chest pain and hypertension for a period of time in the mid-1980's. He also had a heart murmur noted, although such murmur was thought to be of no clinical significance. After the mid-1980's, the veteran stopped taking medication for hypertension, and his blood pressure readings varied between normal and elevated. On examination for retirement in July 1993, his blood pressure was 130/90. After service, blood pressure readings of record continued to vary, and an echocardiogram in April 1997 showed slight valvular regurgitation. The present record does contain a clear record of treatment for hypertension in service, followed by occasional elevated readings in service and after service when the veteran was not taking medication. With the echocardiogram in April 1997 showing some slight valvular regurgitation, there is some evidence that cardiovascular disease or hypertension may be present after discharge from service and may be related to findings in service. The claim for service connection for cardiovascular disease, including hypertension, is plausible and therefore well grounded. The Board will remand this issue (as provided below) for further development. The veteran has been granted service connection for prostatitis, residuals of kidney stones, and residuals of urethral stricture. In service, it is clear that the veteran was treated on various occasions for venereal disease and urethritis. While the present record does not contain any medical opinion considering the matter, a logical question arises as to whether the urethral stricture which has been found is related to the history of venereal disease, kidney stones, or any other disease entity shown initially in service. Such medical findings relating to disability shown in service and after discharge from service indicates that the veteran's claim for service connection for residuals of venereal disease is plausible, and therefore, well grounded. The Board will remand this issue (as provided below) for further development. II. Increased Ratings A veteran's assertion of an increase in severity of a service-connected disorder constitutes a well-grounded claim requiring the VA to fulfill the statutory required duty to assist under 38 U.S.C.A. § 5107 because it is a new claim and not a reopened claim. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). The facts relevant to the issue on appeal have been properly developed, and the statutory duty of the VA to assist the veteran in developing the facts pertinent to his claim for an increased rating for the pertinent claims (except those being remanded) has been satisfied in this case. Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities (38 C.F.R. Part 4) and are intended to represent the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. In addition, the veteran's medical history and current clinical manifestations have been reviewed in the context of all applicable regulations. Specifically, the extent to which the veteran's disability causes pain, weakness, and limitation of function of the affected joint beyond that reflected by the measured limitation of motion of the affected joint has been considered. See DeLuca v. Brown, 6 Vet. App. 321 (1993). IIA. Left Foot The service medical records show that the veteran the removal of a Morton's neuroma in service, and that he complained of left foot pain on occasion during service. On the VA general medical examination in February 1994, the veteran noted his history of Morton's neuroma in service. He had no specific complaints involving the left foot. The physical examination showed scars relating to the surgery for the Morton's neuroma, but the examination was otherwise normal. Gait was normal. A podiatrist in June 1994 noted that the veteran had a 13-year history of left foot trauma and bilateral foot pain. It was noted that there were no recent X-rays, but that a physical examination showed tenderness to palpation of the plantar fasciae of both feet. The diagnosis was chronic pain of both feet. Post-service VA and service department outpatient treatment records fail to show any significant complaints relating to the left foot. On a VA examination in May 1996, the veteran's medical history relating to his feet was reviewed. He had complaints of pain on the dorsal aspect of the left foot, and it was noted that the veteran had orthotic devices which he did not use regularly. On physical examination, there was full range of motion of the ankles, with no evidence of crepitus. There was no palpable tenderness and no pain throughout the range of motion of the ankles. Examination of the feet showed a well-healed surgical scar, residual to surgery for Morton's neuroma. There was no surrounding hypesthesia or loss of surrounding tissue. He had palpable tenderness on the plantar aspect of the foot toward the heel. There were no other bony abnormalities. The diagnoses included no evidence of residual deficit from surgery for Morton's neuroma and history of bilateral plantar fasciitis. On a VA examination in April 1997, the veteran's history was again reviewed. The veteran complained of tenderness and pain over the dorsal surface of the left foot. He stated that he tried to wear the orthotics whenever he could. On physical examination, dorsiflexion of the left foot was to 10 degrees while plantar flexion was to 20 degrees. He had a considerable amount of tenderness around the dorsum of the left foot and plantar fasciitis of both feet. X-rays of the left foot were interpreted as normal. In an addendum in March 1998, the examiner indicated that the diagnosis was Morton's neuroma of the left foot, surgically removed, with residual scarring and chronic pain. Under 38 C.F.R. § 4.71a, Diagnostic Code 5271, limitation of motion of the ankle, a 20 percent evaluation will be assigned where the limitation is marked. A 10 percent evaluation will be assigned where the limitation of motion is moderate. Under Diagnostic Code 5284, foot injuries, a 20 percent evaluation will be assigned where the disability is moderately severe. A moderate disability will be evaluated as 10 percent disabling. Under Diagnostic Code 5279, a 10 percent evaluation will be assigned for unilateral or bilateral anterior metatarsalgia (Morton's disease). In this case, the veteran does have some pain in the left foot. However, gait was normal, and there was normal range of motion in the left ankle. While the veteran does have some pain and tenderness in the left foot, the disability in the left foot is not shown to be of a moderately severe nature. The pain and limitation of function affecting the left foot beyond that reflected by the measured limitation of motion in the affected joint is adequately compensated by the 10 percent evaluation for disability of the left foot. Consequently, the criteria for a rating in excess of 10 percent for disability of the left foot have not been met. IIB. Left Elbow The service medical records show that the veteran was treated on various occasions for complaints of pain and numbness around the left elbow, with an electromyogram showing some left ulnar neuropathy. Surgery on the left elbow was performed in February 1993. On examination for retirement from service in July 1993, the veteran had no complaints involving the left elbow, and there were no abnormal findings relating to disability of the left elbow. On a VA examination in February 1994, the veteran indicated that he had had surgery in 1993 to repair tendinitis of the left elbow. On physical examination, there was a scar of the left elbow, with normal range of motion, and no tenderness. The diagnoses included status following surgery for tendinitis of the left elbow. A statement from an orthopedic surgeon in May 1994 indicates that the veteran had a history of surgery in service for chronic lateral epicondylitis of the left elbow. The VA outpatient treatment reports and service department reports after service indicate that the veteran had occasional complaints involving the left elbow. On a VA orthopedic examination in May 1996, examination of the elbows showed no evidence of fixed deformity, effusion, or erythema. He had full range of motion of both elbows, with extension to 0 degrees, flexion to 160 degrees, and pronation to 90 degrees. Neurological examination was essentially normal. He did have some pain with full flexion of the left elbow. X-rays of the left elbow were essentially normal. The diagnoses included surgical repair of left elbow tendinitis with evidence of pain with full flexion, no other functional impairment appreciated. A separate neurological examination showed no disability of the left elbow. On a VA examination in April 1997, it was indicated that the surgery in service repositioned the tendon in the left elbow in order to increase the range of motion. The veteran, who is right-handed, had no specific complaints relating to the left elbow. He did say that he did have difficulty raising his arms over his shoulders because of the pain in both elbow joints. On physical examination, flexion of the left elbow was to 160 degrees, and extension was to 0 degrees. X-rays of the left elbow showed a linear calcification and some deformity at the lateral condyle. It was suggested that this was post surgical in nature. The diagnoses included residuals of tendinitis following surgery for repair of left elbow joint. Under Diagnostic Codes 5206 and 5207, limitation of motion of the forearm, a 20 percent evaluation will be assigned where flexion is limited to 90 degrees or extension is limited to 75 degrees. A 10 percent evaluation will be assigned where flexion is limited to 100 degrees, or extension is limited to 60 degrees. Under Diagnostic Code 5208, limitation of motion of the forearm, a 20 percent evaluation will be assigned where flexion is limited to 100 degrees and extension is limited to 45 degrees. Under Diagnostic Code 8511, incomplete paralysis of the middle radicular group, a 20 percent evaluation will be assigned where the disability is mild. After the veteran's surgery in service, the medical records failed to indicate any complaints, findings, or clinical studies indicating neurological problems in the left elbow. The veteran does have some pain on motion of the left elbow, but motion of the left elbow was essentially normal on two different VA examinations. He does not meet the criteria for a rating in excess of 10 percent for disability of the left elbow. In addition, the Board finds that the reported complaints of pain, weakness, and limitation of function of the left elbow are descriptive of a mild impairment and are adequately contemplated within the 10 percent evaluation for the disability of the left elbow. A rating in excess of 10 percent for disability of the left elbow is not warranted. IIC. Hemorrhoids The veteran was treated for hemorrhoids on different occasions during service, including a hemorrhoidectomy. On the VA examination in February 1994, the veteran indicated that he had occasional recurrence of the hemorrhoids. On physical examination, there were some external hemorrhoid tags. VA and service department outpatient treatment reports after service show that the veteran complained of bleeding from the rectum on occasion. A notation in April 1996 indicated that examination showed no hemorrhoids. On a VA examination in May 1996, the veteran had no complaints relating to hemorrhoids. Rectal examination was essentially normal. A colonoscopy in November 1996 showed vascular malformations, but was otherwise normal. On a VA examination in April 1997, there were no complaints relating to hemorrhoids. Under 38 C.F.R. § 4.114, Diagnostic Code 7336, a 10 percent evaluation will be assigned where the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 0 percent evaluation will be assigned where the disability is mild or moderate, with lesser symptoms or manifestations. In this case, medical records after service and on various VA examinations fail to show that the veteran has large, thrombotic, or irreducible hemorrhoids or evidence of frequent recurrences. The veteran has indicated that he only has occasional hemorrhoids and the record indicates that these are mild to moderately disabling. In summary, he does not meet the criteria for a compensable evaluation for hemorrhoids. IID. Left Shoulder The service medical records show that the veteran was treated for complaints of pain and dislocations in the left shoulder following trauma. On the general medical examination in February 1994, the veteran complained about pain in the left shoulder with overhead use. The physical examination, which did not contain specific range of motion studies, indicated that there was normal range of motion of the left shoulder, with no tenderness to palpation. X-rays of the left shoulder were suggestive of a loose body in the joint. VA outpatient treatment reports and reports from the outpatient service department failed to show significant complaints relating to the left shoulder after service. A May 1994 statement from an orthopedic surgeon at a service department medical facility indicates that the veteran was being treated with rehabilitation for instability of the left shoulder. On a VA orthopedic examination in May 1996, the veteran provided a history of hyperextension abduction injury of the left shoulder during the early part of his service, with the diagnosis of rotator cuff injury. His current complaints included pain in the left shoulder, particularly exacerbated when lifting objects over his head. He stated that the pain sometimes occurred with no specific change in use of the shoulder, but denied decreased range of motion. He indicated that the pain occurred several times weekly. On physical examination, there was full range of motion of the left shoulder with flexion to a 180 degrees, extension to 50 degrees, internal and external rotation to 90 degrees, abduction to 180 degrees, and adduction to 50 degrees. On a VA examination in April 1997, the veteran complained of a considerable amount of pain in the left shoulder, particularly when he tried to raise the left arm above his head. On physical examination, external and internal rotation of the left shoulder was to 90 degrees, forward elevation was to170 degrees, and abduction was to 120 degrees. X-rays of the left shoulder showed a calcific body in the soft tissues inferior to the left shoulder. The diagnoses included residuals of previous rotator cuff injury of the left shoulder. Under Diagnostic Code 5201, limitation of motion of the minor arm, a 20 percent evaluation will be assigned where there is limitation of motion at the shoulder level. Under Diagnostic Code 5202, impairment of the humerus, minor arm, a 20 percent evaluation will be assigned where there is recurrent dislocation at the scapulohumeral joint, with frequent episodes and guarding of all movements, or with infrequent episodes, and guarding of movement only at shoulder level. The veteran maintains that he has infrequent episodes of dislocation of the left shoulder, and that he had difficulty performing overhead lifting of objects. While range of motion studies indicate only slight limitation of motion of forward flexion of the left shoulder, there is pain and limited use when he raises his arm to or above the shoulder level, the equivalent of guarding at shoulder level. With reasonable doubt resolved in the veteran's favor, the Board believes that the criteria for a 20 percent rating for disability of the left shoulder has been met. However, he does not have ankylosis of the scapulohumeral articulation, limitation of motion of the left arm to 20 degrees from the side, or nonunion in the humerus, which are required for an evaluation in excess of 20 percent. The 20 percent evaluation does adequately reflect the extent of the veteran's pain, weakness, and limitation of function in the left shoulder. IIE. Cervical Spine An MRI in service showed that the veteran has cervical disc disease. He complained of neck pain and pain and numbness in the upper extremities during service, although neurological examinations failed to show cervical radiculopathy. On a VA general medical examination in February 1994, the veteran indicated that he had cervical pain with heavy lifting and sitting too long. While range of motion findings in degrees for the cervical spine were not provided, the examiner indicated that the veteran had a normal range of motion of the cervical spine, with no tenderness to palpation. X-rays of the cervical spine were reported normal. VA and service department outpatient treatment reports after service show that the veteran had occasional complaints of neck pain and numbness in the arms. The veteran complained of pain and numbness in the upper extremities in July 1995, with difficulty lifting objects. On physical evaluation, forward flexion of the cervical spine was within normal limits. Extension backward was to 10 degrees, and rotation was 60 degrees to one side and 40 degrees to another. A MRI of the cervical spine in July 1995 resulted in the diagnostic impression of degenerative changes with herniated disc at C4-C5. And electromyogram in August 1995 showed no evidence of cervical radiculopathy. On a VA examination in May 1996, the veteran related his history of cervical disc disease. An orthopedic examination did not provide range of motion studies of the cervical spine. On neurological examination, sensory examination was slightly inconsistent, and an electromyogram was suggested. An electromyogram in July 1996 was interpreted as showing no evidence of left cervical radiculopathy. On a VA examination in April 1997, the veteran complained of pain and stiffness when he tried to rotate his neck to the left or right. There was also pain on prolonged reading or if he sat for a long period of time. On physical examination, there was loss of the normal cervical curvature. Range of motion studies showed forward flexion of the cervical spine to 20 degrees, extension backward to 35 degrees, left lateroflexion to 20 degrees, right lateroflexion to 25 degrees, rotation to the left to35 degrees, and rotation to the right to 10 to 12 degrees. Rotation of the cervical spine to the left produced pain. The diagnostic impression was sprain/strain of the cervical spine. Under Diagnostic Code 5290, limitation of motion of the cervical spine, a 30 percent evaluation will be assigned where the limitation of motion is severe. A 20 percent evaluation will be assigned where the limitation of motion is moderate, and a 10 percent evaluation will be assigned where such limited motion is slight. Under Diagnostic Code 5293, intervertebral disc syndrome, a 40 percent evaluation will be assigned where the disability is severe; recurring attacks, with intermittent relief. A 20 percent evaluation will be assigned where the disability is moderate, with recurring attacks. The veteran has documented complaints from the various outpatient treatment clinics showing occasional complaints of neck pain, and VA examinations have indicated that the veteran has pain and limitation of function in the cervical spine, especially on rotation of the cervical spine. Various MRI examinations have shown cervical disc disease. Neurological studies have failed to show cervical radiculopathy. The Board finds that the VA examinations have demonstrated moderate disability resulting from intervertebral disc syndrome, or moderate limitation of motion in the cervical spine, as demonstrated by range of motion studies. The various medical records fail to demonstrate that the veteran has severe disability resulting from the cervical disc disease, or severe limitation of motion in the cervical spine. The various medical records demonstrate that the veteran is entitled to a rating of 20 percent, but not higher, for cervical disc disease. IIF. TMJ Syndrome The service medical records show that the veteran did incur trauma to the jaw during service. TMJ syndrome was noted subsequently. On a VA dental examination in February 1994, the veteran's medical history was reviewed. The veteran complained of some discomfort when he opened his mouth wide. He also complained of some locking of the jaw. He stated that he had some soreness when he talked for any length of time and on extended chewing. There was some clicking when chewing. On physical examination, there was a small quantity of bone loss present in the mouth. There was tenderness to palpation. The temporalis and masseter muscles contracted spontaneously when the veteran bit down with firmness. There was a vertical opening well within normal range at 45 plus ml. There were no clicking noises or grinding apparent on examination. The temporomandibular joint had full range of motion. He appeared to have normal or regular lateral movement. X-rays showed that the condyles were asymmetrical with possible spur formations. The diagnosis included some myofascial pain dysfunction and possible joint degeneration, especially on the right side. On a VA examination in May 1996, the veteran's history was again reviewed. He again complained of occasional locking. He indicated that night guards did not work very well for him. He had maximum intercisal opening of 1 3/4 inches. He could go a little further, but was afraid of locking of the jaw. There was a marked deviation of the left upon opening, with midline going to the left 4 to 5 millimeters. X-rays indicated that the right condyle was fifty percent smaller than the left. The diagnosis was TMJ syndrome which caused difficulty chewing, eating, and being comfortable. He also had complaints of headaches, muscle pain, spasms, and difficulty sleeping. A VA neurological examination in July 1997 resulted in the diagnostic impression of mixed tension vascular headaches, and the examiner expressed the opinion that the veteran's headaches did not seem to be related to the TMJ dysfunction. The regulations relating TMJ syndrome were amended while the appeal for a compensable evaluation for this disability was pending. The Board has reviewed the veteran's appeal for a compensable evaluation for TMJ syndrome under both the old and new criteria, and the Board has determined that the veteran is entitled to a 10 percent evaluation, but not higher, for TMJ syndrome under both criteria. See Karnas v. Derwinski, 1 Vet. App. 308 (1991). Under the old criteria for Diagnostic Code 9905, a 20 percent evaluation is assigned for limited motion of the temporomandibular articulation when motion was limited to 1/2 inch (12.7 millimeters). A 10 percent evaluation is assigned when there is any definite limitation of motion interfering with mastication. Under the new criteria, a 20 percent evaluation is assigned where the intercisal range is from 21 to 30 millimeters. A 10 percent evaluation is assigned where the intercisal range is from 31 to 40 millimeters or range of lateral excursion is from 0 to 4 millimeters. In this case, the veteran has a vertical opening that is within normal range of motion, but a deviation to the left upon opening. He also has soreness, pain, and limitation of function on extended use. Considering the slight limitation of motion and limitation of function, the Board finds that he meets the criteria for a 10 percent, but not higher, rating for TMJ syndrome. ORDER The claims for service connection for a chronic organic gastrointestinal disability, a right shoulder disability, a right hip disability, and a disability manifested by numbness of the upper and lower extremities are not well grounded, and are denied.. The claims for service connection for a right foot disability, residuals of venereal disease, and a cardiovascular disability, including hypertension, are well grounded. Entitlement to service connection for a left knee disability is established. This benefit sought on appeal is granted. Entitlement to a rating in excess of 10 percent for disability of the left foot and in excess of 10 percent for disability of the left elbow is not established. Entitlement to a compensable evaluation for hemorrhoids is not established. These benefits sought on appeal are denied. Entitlement to a rating of 20 percent for disability of the left shoulder, but not higher, and entitlement to a 20 percent evaluation for disability of the cervical spine, but not higher, is established. Entitlement to a 10 percent evaluation for TMJ syndrome, but not higher, is established also. The appeal on these issues is granted to the extent indicated, subject to the controlling regulations for the award of monetary benefits. REMAND As described above, the Board has determined that the veteran's claims for service connection for a right foot disability, residuals of venereal disease, and a cardiovascular disability, including hypertension, are well grounded, but need further development prior to final appellate review. In essence, the veteran experienced problems with the right foot before and after service, with varied diagnoses. The VA examiners did not have the benefit of all of the veteran's records for review, and there was no opinion expressed as to whether any current diagnosis is a disability which can be related to disorders or findings noted in service. In addition, it was not indicated whether there was any etiological relationship between any current right foot disability and any service connected disabilities, including whether there was any aggravation of a veteran's nonservice-connected disability by reason of any service-connected conditions. See Allen v. Brown, supra. In a similar manner, the VA examiners did not have the benefit of all of the veteran's medical records when examining the veteran's current cardiovascular status. Specifically, it is noted that the veteran did receive treatment with medication for hypertension during service, and did have various clinical studies relating to his complaints of a heart murmur and chest pain. The recent VA examinations did not determine whether any current clinical manifestations, particularly the manifestations on the electrocardiogram in 1997 and the occasional elevated blood pressure readings after service, had any relationship to complaints or findings in service. In addition, in a similar manner, the veteran has been granted service connection for prostatitis and urethral stricture. The recent VA examinations did not provide any reasons and bases allowing a determination whether the urethral stricture was proximately due to, or the result of, any residuals of venereal disease, or to the veteran's history of kidney stones. The Board finds that a new examination should be conducted to review the interrelationship of such disabilities, and that the question of entitlement to a compensable evaluation for kidney stones should be deferred, pending this new examination. Finally, the veteran's VA outpatient treatment reports from January 1997 should be obtained. In view of the above, the issues of service connection for a right foot disability, residuals of venereal disease, and cardiovascular disease, and the issue of entitlement to a compensable evaluation for residuals of kidney stones should be remanded to the regional office for the following actions: 1. The regional office should obtain copies of all of the veteran's VA outpatient treatment reports beginning from January 1997. 2. The regional office should make arrangements for special podiatry, orthopedic, cardiovascular, urology examinations of the veteran to determine the nature and extent of any disability present. All clinical tests which are deemed necessary for the examinations should be conducted. The examiners should express an opinion concerning whether there is any etiological relationship between any disability found and any disorder treated in service, disability for which service connection has been granted, or aggravation of any nonservice-connected disability by reason of a service connected condition. See the criteria in Allen v. Brown, supra . Specifically, the cardiovascular examiner should be requested to express an opinion concerning whether the veteran currently has hypertension or any cardiovascular disease (heart disease) that is related to disabilities found or treated in service. The podiatry examiner should express an opinion concerning whether the veteran has pes planus, plantar fasciitis, hammertoes, or any other disability of the right foot that is etiologically related to any disorder treated or found in service, or any service connected disability. The orthopedic examiner should discuss whether any non-service connected disability found has been aggravated by a service connected disability. The urologist should express an opinion concerning whether the veteran has residuals of venereal disease, and whether such disability, if present, is etiologically related to any disability treated in service, or any service-connected disability. Such examiner should express an opinion as to whether the urethral stricture, for which service connection has been granted, is related to venereal disease or the history of kidney stones. The claims folder must be made available to the examiners in conjunction with the examinations of the veteran. When the above actions have been completed, the regional office should again review the remaining claims for service connection and an increased rating, in accordance with the pertinent regulations and all Court decisions. If any claim is denied, the case should be processed in accordance with appropriate appellate procedures, including the issuance of supplemental statement of the case. No action is required of the veteran until and unless he receives further notice. The purpose of this REMAND portion is to procure clarifying data. The Board intimates no opinion, either legal or factual, as to the ultimate decision warranted in this case. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). ROBERT D. PHILIPP Member, Board of Veterans' Appeals Error! Not a valid link.