Citation Nr: 0004266 Decision Date: 02/17/00 Archive Date: 02/23/00 DOCKET NO. 98-07 696 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for dysthymia. 2. Entitlement to an evaluation in excess of 10 percent for hammertoes of the right foot, with osteoarthritis of the first metatarsal. 3. Entitlement to service connection for a right elbow disorder. 4. Entitlement to service connection for a right knee disorder. 5. Entitlement to an evaluation in excess of 10 percent for degenerative arthritis of the lumbosacral spine for the period from May 1, 1996 until July 9, 1998 6. Entitlement to an evaluation in excess of 20 percent for degenerative arthritis of the lumbosacral spine for the period on and after July 9, 1998. 7. Entitlement to an increased evaluation for a hiatal hernia, with gastroesophageal reflux disease, currently evaluated as 10 percent disabling. 8. Entitlement to an evaluation in excess of 10 percent for bronchial asthma for the period from May 1, 1996 until July 23, 1998. 9. Entitlement to an evaluation in excess of 10 percent for sleep apnea for the period from May 1, 1996 until July 23, 1998. 10. Entitlement to an evaluation in excess of 50 percent for asthma with sleep apnea for the period on and after July 24, 1998. 11. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD A. C. Mackenzie, Associate Counsel INTRODUCTION The veteran served on active duty from February 1976 to February 1980 and from February 1981 to April 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio in January 1997, April 1998, and October 1998. With regard to the veteran's degenerative arthritis of the lumbosacral spine, the Board observes that, in an October 1998 rating decision, the RO increased this evaluation from 10 percent to 20 percent, effective from July 9, 1998. As this increase was not effectuated as of the date of the veteran's initial claim in May 1996, both the prior 10 percent evaluation and the current 20 percent evaluation are at issue in this case. Similarly, the RO initially granted service connection for bronchial asthma and sleep apnea as separate disorders, with 10 percent evaluations assigned for both disorders. However, in an October 1998 rating decision, the RO combined the two disorders and assigned a single 50 percent evaluation, which still represents less than the maximum available under the revised diagnostic criteria for respiratory disorders. See AB v. Brown, 6 Vet. App. 35, 38 (1993); 38 C.F.R. § 4.96 (1999). The veteran's claims on appeal also initially included entitlement to an increased evaluation for hypertension; entitlement to a compensable evaluation for residuals of an avulsion fracture of the distal phalanx of the right ring finger; entitlement to service connection for an upper back disorder, to include as secondary to the service-connected low back disorder and/or asthma; entitlement to service connection for injuries to the little and ring fingers of the left hand, to include as secondary to the service-connected degenerative arthritis of the lumbosacral spine; entitlement to service connection for lymphadenopathy; and entitlement to service connection for cardiac arrhythmia. However, during his August 1999 VA Video Conference hearing before the undersigned Board member, the veteran indicated that he was limiting his appeal to the issues listed above and that he was withdrawing his appeal with regard to the other issues. See 38 C.F.R. § 20.204 (1999). In a letter received by the RO in December 199, the veteran raised the issue of entitlement to service connection for allergic rhinitis. This claim has not been developed by the RO to date, and the Board therefore refers it back to the RO for appropriate action. The claim of entitlement to service connection for a right knee disorder will be addressed in both the REASONS AND BASES and the REMAND sections of this decision. The claims of entitlement to an evaluation in excess of 10 percent for degenerative arthritis of the lumbosacral spine for the period from May 1, 1996 until July 9, 1998; an evaluation in excess of 20 percent for degenerative arthritis of the lumbosacral spine for the period on and after July 9, 1998; an increased evaluation for a hiatal hernia, with gastroesophageal reflux disease; an evaluation in excess of 10 percent for bronchial asthma for the period from May 1, 1996 until July 23, 1998; an evaluation in excess of 10 percent for sleep apnea for the period from May 1, 1996 until July 23, 1998; an evaluation in excess of 50 percent for asthma with sleep apnea for the period on and after July 24, 1998; and TDIU will be addressed solely in the REMAND section of this decision. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of this appeal has been obtained by the RO. 2. The veteran's dysthymia is manifested by such symptoms as considerable anxiety and depression, with feelings of helplessness and hopelessness; his Global Assessment of Functioning scores have ranged from 52 to 60, and he is currently employed. 3. The veteran's hammertoes of the right foot, with osteoarthritis of the first metatarsal, are productive of limited motion of the right foot and pain with motion testing; these symptoms are more than moderate in degree. 4. There is no competent medical evidence of a nexus between a current right elbow disorder and service. 5. There is competent medical evidence of a nexus between a current right knee disorder and service. CONCLUSIONS OF LAW 1. The criteria for a 50 percent evaluation for dysthymia have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9433 (1999); 38 C.F.R. § 4.132, Diagnostic Code 9405 (1996). 2. The criteria for a 20 percent evaluation for hammertoes of the right foot, with osteoarthritis of the first metatarsal, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5010, 5284 (1999). 3. The claim of entitlement to service connection for a right elbow disorder is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The claim of entitlement to service connection for a right knee disorder is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Claims for increased evaluations A. Applicable laws and regulations As a preliminary matter, the Board finds that the veteran's claims for increased evaluations are plausible and capable of substantiation and are therefore well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). A claim that a service-connected condition has become more severe is well grounded when 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, 631-32 (1992). The Board is also satisfied that all relevant facts have been properly developed and that no further assistance to the veteran is required in order to comply with the VA's duty to assist him in developing the facts pertinent to his claims under 38 U.S.C.A. § 5107(a) (West 1991). Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). But see generally Fenderson v. West. 12 Vet. App 119 (1999) (concerning the application of "staged" ratings in certain cases in which a claim for a higher evaluation stems from an initial grant for service connection for the disability at issue). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (1999). B. Dysthymia In a January 1997 rating decision, the RO granted service connection for dysthymia and assigned a noncompensable (zero percent) evaluation, effective from May 1996, on the basis of in-service treatment for a depressed mood and anxiety and the results of a June 1996 VA examination. During this examination, the veteran was noted to be mildly depressed. He denied guilt feelings, suicidal or homicidal thoughts, mood swings, phobias, panic attacks, obsessions, and compulsions. He was alert and oriented to time, place, and person. No memory deficiencies were noted. The veteran's speech was logical, relevant, and coherent. His thought processes were linear and goal-directed, with no looseness of associations, tangentiality, or circumstantiality. His thought content centered around his medical problems. Judgment was noted to be good in regard to daily living but poor regarding his mental disorder. The Axis I diagnosis was dysthymia, late onset, and a Global Assessment of Functioning (GAF) score of 60 was assigned. The examiner noted that there might be "a biological component" to the veteran's dysthymia, to which "he may have a genetic vulnerability and given the right psychosocial stressors, could result in depression." An October 1997 VA treatment record indicates that the veteran was treated for complaints of anxiety and depression. During his July 1998 VA psychiatric examination, the veteran reported past depressive episodes lasting from one week to one month, but he noted that, more recently, he seemed depressed only four or five days every three weeks. He stated that he was currently taking Buspar and Clonopin and indicated a reduced level of energy. However, he reported no feelings of hopelessness, suicidal or homicidal thoughts, psychotic or manic symptoms, or obsessive-compulsive symptoms. Upon examination, the veteran was alert and oriented to time, place, and person. His thought form was goal-directed, oriented, and logical. His mood was not depressed but was anxious. His affect was somewhat restricted but appropriate, and his thought content was negative for suicidal or homicidal thoughts, hallucinations, delusions, or manic symptoms. No memory abnormalities were noted. The diagnostic impression was a chronic adjustment disorder with an anxious and depressed mood, and a GAF score of 58 was assigned. In view of these examination results, the RO granted a 10 percent evaluation, effective May 1996, in an October 1998 rating action. The veteran appeared for a VA Video Conference Hearing before the undersigned Board member in August 1999. During this hearing, he reported panic attacks, irritability, depression, and anxiety. He also submitted lay statements from people familiar with him, who further described his psychiatric impairment. The claims file also includes VA outpatient treatment reports from August and September of 1999. The August 1999 report indicates that the veteran had made very little progress in terms of his anxiety and depression in the past 2.5 years and appeared "completely unemployable," with severe difficulty in participating in any kind of vocational rehabilitation program. However, the September 1999 report indicates that the veteran was currently working as a software specialist, although the examiner noted that, up until about a year previously, the veteran had been unable to work on account of his pain and anxiety. The examiner noted that the veteran was not suicidal or homicidal and did not appear to be depressed. Moreover, the examiner indicated that the veteran was able to function despite "a great deal of anxiety." In a statement submitted by the veteran in September 1999, a VA psychiatrist noted worsening anxiety and panic attacks but indicated that the veteran "has to suffer through them because he does not want to lose his job." This psychiatrist also noted that the veteran's psychiatric condition had led him to feelings of hopelessness and helplessness to the extent that, at least until he obtained his current job, would lead him to feel "that his life was not worth living anymore." The diagnoses were a chronic adjustment disorder with a depressed mood and generalized anxiety disorder. The doctor assigned a GAF score of 52 and noted that, so long as the veteran had chronic pain, he was likely to have the depressive and anxiety symptoms that impacted on his quality of life, including relationships, job performance, and sense of self-worth. In evaluating the veteran's dysthymia, the Board observes that his original claim was received by the RO in May 1996. The Board notes that, by regulatory amendment effective November 7, 1996, substantive changes were made to the schedular criteria for evaluating mental disorders, including dysthymia, formerly set forth in 38 C.F.R. §§ 4.125-4.132 (1996) (redesignated as 38 C.F.R. §§ 4.125-4.130 (1999)). See 61 Fed. Reg. 52695-52702 (1996). Generally, when the laws or regulations change while a case is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). However, in Rhodan v. West, 12 Vet. App. 55 (1998), the United States Court of Appeals for Veterans Claims (Court) noted that, where compensation is awarded or increased "'pursuant to any Act or administrative issue, the effective date of such an award or increase ... shall not be earlier than the effective date of the Act or administrative issue.'" Id. at 57. See 38 U.S.C.A. § 5110(g) (West 1991). As such, the Court reasoned that this rule prevents the application of a later, liberalizing law to a claim prior to the effective date of the liberalizing law. In this case, the RO has assigned a 10 percent evaluation for the veteran's dysthymia under both the prior and revised sets of applicable criteria. Under the criteria of 38 C.F.R. § 4.132, Diagnostic Code 9405 (1996), in effect through November 6, 1996, a 10 percent evaluation for dysthymia was warranted in cases of emotional tension or other evidence of anxiety productive of mild social and industrial impairment, albeit less than that for a 30 percent evaluation. A 30 percent evaluation was in order in cases of definite impairment in the ability to establish or maintain effective and wholesome relationships with people, where the psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. A 50 percent disability evaluation encompassed situations where the ability to establish or maintain effective or favorable relationships with people is considerably impaired, and, by reason of psychoneurotic symptoms, the reliability, flexibility, and efficiency levels are so reduced as to result in considerable industrial impairment. A 70 percent evaluation was warranted for situations where the ability to establish and maintain effective or favorable relationships with people is severely impaired, with psychoneurotic symptoms of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. Under the revised criteria of 38 C.F.R. § 4.130, Diagnostic Code 9433 (1999), a 10 percent evaluation is warranted for a dysthymic disorder which is productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent evaluation is warranted for occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as a depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events. A 50 percent disability evaluation encompasses a dysthymic disorder manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for a dysthymic disorder manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or an inability to establish and maintain effective relationships. In reviewing the recent medical evidence of record, the Board finds that the veteran's symptoms from dysthymia are not adequately contemplated by the assigned 10 percent evaluation. In this regard, the Board observes that these symptoms include a restricted affect, a depressed mood, and judgment that was noted to be good with regard to daily living but poor with regard to the veteran's mental disorder. Significantly, the Global Assessment of Functioning (GAF) scores assigned for the veteran's disorder have ranged from 52 to 60. A GAF score between 51 and 60, under the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), signifies moderate symptoms or moderate difficulty in social and occupational functioning. In view of the noted symptoms and the assigned GAF scores, the Board finds that the veteran's social and industrial impairment resulting from his dysthymia is more appropriately characterized as "definite" than as "mild." As such, a higher evaluation, of at least 30 percent is warranted. Additionally, the Board finds that there is a question as to whether an even higher evaluation is in order for the veteran's dysthymia. In this regard, the Board observes that the veteran's recent psychiatric examinations have revealed no suicidal or homicidal ideation, psychotic symptoms, memory abnormalities, or speech deficiencies. However, the VA psychiatrist whose statement was received in September 1999, who assigned the veteran a GAF score of 52, noted that the veteran's anxiety and depression symptoms would impact significantly on his social and industrial functioning as long as he suffered from chronic pain. Moreover, the VA treatment records from August and September of 1999 reflect a substantial level of social industrial impairment; the September 1999 record, in which the veteran's examiner conceded that the veteran was "able to function," indicates "a great deal of anxiety." In view of this, and resolving all reasonable doubt in favor of the veteran, the Board finds that the veteran's psychiatric impairment is more properly characterized as "considerable" than as "definite." Under the prior criteria of Diagnostic Code 9405, this warrants a 50 percent evaluation. See 38 U.S.C.A. § 5107(b) (West 1991). Nevertheless, the Board does not find that a higher evaluation, of 70 percent, is in order for the veteran's dysthymia. In light of the prior criteria of Diagnostic Code 9405, the veteran's psychiatric impairment appears to be more properly characterized as "moderate" rather than "severe." In reaching this determination, the Board has again considered the range of GAF scores from 52 to 60; as noted above, these scores signify "moderate" impairment under DSM-IV. While the evidence as a whole suggests a disability picture which is, in fact, more than moderate in degree, the Board cannot ignore the fact that the veteran is currently working or the September 1999 notation from the VA doctor who stated that the veteran was able to function despite a great deal of anxiety. This doctor also noted that the veteran was not in a depressed mood at that time. Moreover, in regard to the revised criteria of Diagnostic Code 9433, the Board observes that the symptoms noted in the criteria for a 70 percent evaluation, set forth above, have not been shown. Specifically, the evidence dated on and after November 7, 1996 does not indicate suicidal ideation, obsessional rituals, speech deficiencies, impaired impulse control, spatial disorientation, or neglect of personal hygiene. In conclusion, the Board finds that the recent evidence of record presents a picture of a veteran whose psychiatric symptoms, particularly depression and anxiety, have resulted in considerable, but not severe or complete, limitation of occupational functioning and social participation. In reaching this conclusion, the Board observes that the veteran has been diagnosed with several psychiatric disorders aside from dysthymia, including adjustment and anxiety disorders, but the Board has considered all of the veteran's psychiatric symptomatology in conjunction with his service-connected dysthymia because his examiners have not clearly indicated which symptoms are attributable to particular diagnoses. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (when it is not possible to separate the effects of a nonservice- connected condition from those of a service-connected condition, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service- connected condition). Moreover, the Board observes that, given the frequency of the veteran's psychiatric treatment and the variable nature of the severity of his dysthymia, "staged" evaluations are not warranted in this case. See Fenderson v. West, supra. Rather, the evaluation for the veteran's service-connected dysthymia is appropriately increased to 50 percent, but not more. C. Hammertoes of the right foot In a July 1980 rating decision, the RO granted service connection for residuals of a fracture of the right fifth metatarsal in light of in-service evidence of such a fracture during service. A noncompensable (zero percent) evaluation was assigned, effective from February 1980. In a January 1997 rating decision, the RO expanded this grant to include hammertoes of the 2nd, 3rd, and 4th toes and osteoarthritis of the head of the first metatarsal of the right foot. A 10 percent evaluation was assigned, effective from May 1996. This evaluation has since remained in effect and is at issue in this case. In the January 1997 rating decision, the RO cited the results from the veteran's June 1996 VA feet examination. During this examination, the veteran reported a recurrent problem with ingrown toenails and noted that he had the toenail of his right great toe removed on several occasions. He also described a sharp, stinging pain in the right foot. Upon examination, the veteran had problems with standing on his toes and stated that he did experience some pain in the metatarsal. When standing on his heels, the veteran experienced pain in the Achilles tendon. He was not capable of supination and pronation because of pain in the metatarsal. Some prominence of the great toe at the proximal phalange bilaterally was noted; it was tender on palpation. The veteran had a normal gait, with no skin abnormalities. The diagnoses were a history of Achilles tendinitis; a history of bilateral calcaneus spurs; a history of a fracture of the fifth metatarsal times two, with residual intermittent edema and pain; hammertoes; and osteoarthritis. X-rays revealed 2nd, 3rd, and 4th hammertoes bilaterally, with spurs at the head of the first metatarsal bone, suggesting some early osteoarthritic changes, with some subchondral cyst formation. In July 1996, the veteran underwent a bunionectomy, with an osteotomy and K-wire, at the Wright Patterson Air Force Base. No complications were noted in conjunction with this surgery. The veteran underwent a second VA foot examination in July 1998, during which he reported right foot pain when walking without shoes. Upon examination, some tenderness and swelling was noted over the proximal right fifth metatarsal area. There was no bony prominence, although the area was wider than on the left. There was a chronic fungal infection of the right great toenail. The veteran had no dorsiflexion but could plantar flex the right foot 35 degrees. He had a somewhat asymmetric gait and seemed to put more weight on the left leg than on the right. The examiner noted a modest hammer toe effect but noted that "this is not marked." The diagnosis was a history of a fracture of the proximal right fifth metatarsal with residual pain and swelling; the examiner noted that "[t]his is intermittent and is particularly a problem with walking barefoot." X-rays revealed evidence of interval bunionectomy, with no other changes of the right foot noted. In March 1999, the veteran underwent a third VA feet examination, during which he complained of chronic pain of the feet and a fungus of the great toenail and the fourth and fifth toenail of the right foot. Upon examination, the veteran did not have obvious hammertoes when sitting with his legs and feet dangling. However, he had hammertoes when standing and tipping on his toes, particularly with the second, third, and fourth toes of each foot. Tenderness on the metatarsals of each foot and on the plantar surfaces of each foot was noted on examination. The toenails of the right foot, notably the great toenail and the fourth and fifth toenails, were very thick and yellowed on examination. The veteran was capable of rising on his toes but had considerable pain with range of motion. He could stand on his heels, supinate, and pronate, but he was unable to squat because of his back pain and right knee pain. Diagnoses included onychomycosis of the right toenail and fourth and fifth digits; bilateral eczema of the feet, plantar fasciitis; status post bunionectomy of the right foot, with a residual scar and associated numbness; a small bunion of the left foot; and minimal degenerative arthritis of both feet. X-rays were negative for a fractures or dislocation but revealed very minimal spur formation, suggesting minimal degenerative arthritic changes. During his August 1999 VA Videoconference hearing, the veteran indicated that he still suffered from right foot pain but noted that he was not currently receiving treatment for this disability. In this case, the RO has evaluated the veteran's hammertoes of the right foot at the 10 percent rate under 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5284 (1999). Under Diagnostic Code 5010, arthritis due to trauma and substantiated by x-ray findings is rated as degenerative arthritis under Diagnostic Code 5003. Under this code section, degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined and not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under Diagnostic Code 5284, a moderate foot injury warrants a 10 percent evaluation. A 20 percent evaluation is in order for a moderately severe foot injury. In the case of a severe foot injury, a 30 percent evaluation is warranted. In this case, the veteran's VA examinations have shown symptomatology that does not appear to be fully contemplated by the currently assigned 10 percent evaluation. The June 1996 VA examination revealed that the veteran was not capable of supination and pronation because of pain in the metatarsal. During his July 1998 VA examination, the veteran could plantar flex the right foot 35 degrees but had no dorsiflexion. The March 1999 VA examination did reveal that the veteran could stand on his heels, supinate, and pronate, but he had considerable pain with range of motion. See 38 C.F.R. §§ 4.40, 4.45 (1999); see also DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1996). In view of these symptoms, the Board finds that the veteran's right foot symptomatology is more appropriately described as moderately severe than as moderate; as such, a 20 percent evaluation is warranted. However, the Board does not find that an even higher evaluation, of 30 percent, is in order for his right foot disorder. In this regard, the Board notes that, while the January 1997 VA examination revealed that the veteran was not capable of supination and pronation, his gait was described as normal. The veteran's July 1998 VA examination revealed a modest hammer toe effect that was described as "not marked." Also, the March 1999 VA examination revealed that the veteran was capable of rising on his toes and standing on his heels, albeit with pain. There is also no evidence of right claw foot (pes cavus), with marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, and marked varus deformity (the criteria for a 30 percent evaluation under Diagnostic Code 5278); or severe malunion or nonunion of the metatarsal bones (the criteria for a 30 percent evaluation under Diagnostic Code 5283). Overall, the Board finds that the veteran's right foot symptomatology is much more appropriately characterized as moderately severe than as severe, and, as such, an increased evaluation of 20 percent, and not more, is warranted under Diagnostic Code 5284. D. Conclusion The Board has based its decision in this case upon the applicable provisions of the VA's Schedule for Rating Disabilities. The veteran has submitted no evidence showing that the service-connected disabilities at issue in this case have markedly interfered with his employment status beyond that interference contemplated by the assigned evaluations. The Board has fully considered the veteran's evident industrial impairment resulting from dysthymia in granting a 50 percent evaluation for this disorder. There is also no indication that these disorders have necessitated frequent periods of hospitalization during the pendency of this appeal. As such, 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) (1999). See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 94- 95 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). II. Entitlement to service connection for a right elbow disorder Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303(a) (1999). 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Additionally, service connection is warranted for certain chronic diseases, including arthritis, which are manifested to a degree of 10 percent or more within one year following separation from service. 38 C.F.R. §§ 3.307, 3.309 (1999). The initial question which must be answered in this case, however, is whether the veteran has presented a well-grounded claim for service connection. The veteran has "the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual" that a claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991); Robinette v. Brown, 8 Vet. App. 69, 73 (1995). A well-grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of § [5107]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In the absence of evidence of a well-grounded claim, there is no duty to assist the claimant in developing the facts pertinent to his claim, and the claim must fail. See Grivois v. Brown, 6 Vet. App. 136, 140 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). To establish that a claim for service connection is well grounded, a veteran must submit medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Epps v. Gober, 126 F.3d 1464, 1468 (1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); see also Grottveit v. Brown, 5 Vet. App. at 93. The nexus requirement may be satisfied by evidence showing that a chronic disease subject to presumptive service connection was manifested 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). The Court has recently indicated that, alternatively, a claim may be well grounded based on application of the rule for chronicity and continuity of symptomatology, as set forth in 38 C.F.R. § 3.303(b) (1999). The Court held that the chronicity provision applies where there is evidence, regardless of its date, which shows that a veteran had a chronic condition either in service or during an applicable presumption period and that the veteran still has such a condition. See Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). That evidence must be medical, unless it relates to a condition that the Court has indicated may be attested to by lay observation. Id. If the chronicity provision does not apply, a claim may still be well grounded or reopened on the basis of 38 C.F.R. § 3.303(b) "if the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology." Savage v. Gober, 10 Vet. App. at 498. The Board has reviewed the veteran's service medical records and observes that they are entirely negative for complaints of, or treatment for, right elbow symptomatology. Results from a post-service electromyograph study (EMG) of the right upper extremity, dated in July 1996, were normal. An October 1996 treatment record from Wright Patterson Air Force Base indicates that the veteran reported right elbow pain that he had noted subsequent to a "squeezing test" in May 1996. However, the veteran reported that this pain had resolved, and no right elbow symptomatology was noted upon examination. A December 1998 VA orthopedic examination revealed some pain elicited when the right medial epicondyle was palpated, and a diagnosis of a new onset of mild medial epicondylitis of the right elbow was rendered. However, the examiner provided no further information regarding the etiology of this disability. While the December 1998 VA orthopedic examination report indicates a current right elbow disorder, there is no competent medical evidence of record suggesting a nexus between such a disorder and service. Indeed, the only evidence of record supporting the veteran's claim is his own lay opinion, as indicated in several lay statements submitted during the pendency of this appeal and in the testimony from his August 1999 VA Video Conference hearing. However, as the veteran has not been shown to possess the requisite medical expertise necessary to render a competent opinion regarding etiology, his lay contentions provide an insufficient basis upon which to find his claims to be well grounded. See Grottveit v. Brown, 5 Vet. App. at 93. See also LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (evidence which is simply information recorded by a medical examiner and unenhanced by any additional medical commentary from that examiner does not constitute competent medical evidence); Robinette v. Brown, 8 Vet. App. at 77 (a lay account of a physician's statement, "filtered as it [is] through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute 'medical' evidence"). Accordingly, as a well-grounded claim must be supported by evidence, not merely allegations, the veteran's claim for service connection for a right elbow disorder must be denied as not well grounded. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). As the veteran's claim is not well grounded, the VA has no further duty to assist the veteran in developing the record to support this claim. See Epps v. Gober, 126 F.3d at 1467-68. The Board observes that the RO denied this claim on its merits in the appealed April 1998 rating decision but continued this denial in a March 1999 Supplemental Statement of the Case on the basis that the claim was not well grounded. As indicated above, the Board has denied this same claim as not well grounded. However, the Court has held that "when an RO does not specifically address the question whether a claim is well grounded but rather, as here, proceeds to adjudication on the merits, there is no prejudice to the veteran solely from the omission of the well-grounded- claim analysis." Meyer v. Brown, 9 Vet. App. 425, 432 (1996). Furthermore, the Board is not aware of the existence of additional relevant evidence that could serve to make the veteran's claim well grounded. As such, there is no further duty on the part of the VA under 38 U.S.C.A. § 5103(a) (West 1991) to notify the veteran of the evidence required to complete his application for service connection for the claimed disability. See McKnight v. Gober, 131 F.3d 1483, 1484-85 (Fed. Cir. 1997). II. Entitlement to service connection for a right knee disorder As a preliminary matter, the Board finds that the veteran's claim for service connection for a right knee disorder is plausible and capable of substantiation and, therefore, is well grounded under the provisions of 38 U.S.C.A. § 5107(a) (West 1991). The Board has based this preliminary finding on the veteran's military retirement medical history report from March 1996, which contains complains of current right knee problems, and a June 1998 statement from James Pettey, M.D., who described the veteran's current right knee meniscal tear in conjunction with in-service right knee symptomatology. ORDER A 50 percent evaluation for dysthymia is granted, subject to the laws and regulations governing the payment of monetary benefits. An evaluation of 20 percent for hammertoes of the right foot, with osteoarthritis of the first metatarsal, is granted, subject to the laws and regulations governing the payment of monetary benefits. A well-grounded claim not having been submitted, service connection for a right elbow disorder is denied. The claim of entitlement to service connection for a right knee disorder is found to be well grounded. REMAND The VA has a duty to assist the veteran in the development of facts pertinent to his well-grounded claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103 (1999); Talley v. Brown, 6 Vet. App. 72, 74 (1993). This duty includes securing private and VA medical records to which a reference has been made, as well as conducting a thorough and contemporaneous medical examination of the veteran. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1993). If an examination report is incomplete, the Board must await its completion, or order a new examination, before deciding the veteran's claim. Abernathy v. Principi, 3 Vet. App. 461, 464 (1992). In this regard, the Board observes that the veteran's claim for service connection for a right knee disorder has been found to be well grounded, as there is competent medical evidence suggesting that there is a nexus between a current right knee disorder and service. However, the Board observes that, to date, the veteran has not been afforded a VA examination for the purpose of determining the etiology of this disability, based on a review of the entire record, and this should be accomplished prior to the Board's adjudication of the veteran's claim. Also, during his August 1999 VA Video Conference hearing, the veteran indicated that he had received treatment for his service-connected low back disorder from several private doctors in the past year. He also indicated that he had received treatment in the past year at the Wright Patterson Air Force Base for his service-connected hiatal hernia, with gastroesophageal reflux disease. Records of this noted treatment should be obtained, if possible, before the Board adjudicates the veteran's claims for higher evaluations for these disabilities. In regard to the issues on appeal involving asthma and sleep apnea, the Board observes that the veteran has recently indicated in a December 1999 letter that he is seeking service connection for allergic rhinitis. He asserts that this disorder caused his asthma and that such was explained to him during a recent allergy clinic visit at the VA medical facility in Cincinnati. Since this disability is classified as a disability of the respiratory system, as with asthma and sleep apnea, the Board observes that there may be overlapping symptomatology and that, as such, the claim for service connection for allergic rhinitis should be developed prior to the Board's determinations of the claims involving asthma and sleep apnea. The Board notes further, that a disposition on this service connection issue could potentially affect a disposition on the issue of the veteran's entitlement to a TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (concerning issues that are "inextricably intertwined"). In addition, the Board notes that at the August 1999 personal hearing before the undersigned, the veteran indicated that he had exacerbations of his asthma numerous times per year and he indicated that he had been on Prednisone for wheezing as recent as three months prior to the hearing; he also indicated that he received regular treatment for his respiratory disorders. Particularly since the RO is requesting that the Board conduct a search for additional medical records, as indicated above, the Board finds that an additional search for records relating to the veteran's asthma and sleep apnea is necessary. With regard to the veteran's claim of entitlement to TDIU, the Board observes the determination of this matter could well be affected by the RO's determinations of the claims for service connection and increased evaluations on remand as well as by the Board's decision, above, on two of the appealed issues. The Court has stated that two or more issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue, here the claim of entitlement to TDIU, cannot be rendered until the other issues, here, the claims for service connection and increased evaluations, have been considered. See Harris v. Derwinski, supra. Accordingly, in order to fully and fairly adjudicate the noted claims, this case is REMANDED to the RO for the following action: 1. The RO should contact the veteran and request that he provide the names and addresses of all medical providers who have treated him for low back, gastrointestinal, or respiratory disorders since January 1999. A specific request should be made for recent treatment records of the veteran from Wright Patterson Air Force, not already of record. 2. After securing the necessary releases, the RO should request any records of medical treatment which are not currently associated with the veteran's claims file. Any records secured by the RO must be included in the veteran's claims file. If the search for such records has negative results, documentation from the contacted entities to that effect should be included in the veteran's claims file. 3. Then, the RO should schedule the veteran for a VA examination to determine the etiology, nature, and extent of his right knee disorder. The veteran's claims file should be made available to the examiner prior to the examination, and the examiner is requested to review the entire claims file in conjunction with the examination. All necessary tests and studies should be performed. Based on a review of the claims file and the clinical findings of the examination, the examiner is requested to provide a diagnosis for any current right knee disorder(s). The examiner is also requested to offer an opinion as to whether it is at least as likely as not that current right knee disorder, if present, is related to the veteran's period of active service. A complete rationale should be given for all opinions and conclusions expressed in a typewritten report. 4. The RO should then adjudicate the veteran's claim of entitlement to service connection for allergic rhinitis. The veteran should be provided notice of this determination and of his appellate and procedural rights. If the veteran files a timely notice of disagreement as to this issue, the RO should ensure that the veteran is afforded the opportunity to complete all procedural steps necessary to advance an appeal before the Board in accordance with the provisions of 38 U.S.C.A. § 7105 (West 1991) and 38 C.F.R. § 20.200 (1999). 5. After completion of all requested development, the RO should again adjudicate the veteran's claims of entitlement to service connection for a right knee disorder; an evaluation in excess of 10 percent for degenerative arthritis of the lumbosacral spine for the period from May 1, 1996 until July 9, 1998; an evaluation in excess of 20 percent for degenerative arthritis of the lumbosacral spine for the period on and after July 9, 1998; an increased evaluation for a hiatal hernia, with gastroesophageal reflux disease; an evaluation in excess of 10 percent for bronchial asthma for the period from May 1, 1996 until July 23, 1998; an evaluation in excess of 10 percent for sleep apnea for the period from May 1, 1996 until July 23, 1998; an evaluation in excess of 50 percent for asthma with sleep apnea for the period on and after July 24, 1998; and TDIU. If the determination of any of these issues remains adverse to the veteran, he and his representative should be furnished with a Supplemental Statement of the Case and given an opportunity to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The purpose of this REMAND is to obtain additional development and adjudication. The Board intimates no opinion, either factual or legal, as to the ultimate outcome warranted in this case. The veteran has the right to submit additional evidence and argument on this matter. See generally Kutscherousky v. West, 12 Vet. App. 369 (1999). However, no action is required of the veteran until he is so notified by the RO. S. L. KENNEDY Member, Board of Veterans' Appeals