Citation Nr: 0004351 Decision Date: 02/18/00 Archive Date: 02/23/00 DOCKET NO. 95-17 386 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUES 1. Entitlement to benefits under 38 U.S.C.A. § 1151 for a heart disorder, claimed to have resulted from treatment at a VA medical facility. 2. Entitlement to an increased rating for a left knee disorder, currently evaluated as 30 percent disabling. 3. Entitlement to an increased rating for a right knee disorder, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Richard Giannecchini, Associate Counsel INTRODUCTION The veteran had active military service from January 1940 to June 1945. A perfected appeal to the Board of Veterans' Appeals (Board) of a particular decision entered by a Department of Veterans Affairs (VA) regional office (RO) consists of a Notice of Disagreement (NOD) in writing received within one year of the decision being appealed and, after a Statement of the Case (SOC) has been furnished, a substantive appeal (VA Form 9) received within 60 days of the issuance of the Statement of the Case or within the remainder of the one-year period following notification of the decision being appealed. With respect to entitlement to benefits under 38 U.S.C.A. § 1151, the present appeal arises from a July 1996 rating decision in which the RO denied the veteran's claim. The veteran filed an NOD in January 1997, and the RO issued an SOC the following month. The veteran filed a substantive appeal in February 1997. A supplemental statement of the case (SSOC) was issued in April 1999. With respect to an increased rating for left and right knee disorders, the present appeal arises from an October 1994 rating decision, in which the RO denied the veteran's claims. The veteran's left knee was previously rated as 30 percent disabling, with an effective date from November 1974; and the right knee was previously rated as 10 percent disabling, with an effective date from November 1975. The veteran filed an NOD in February 1995, and the RO issued an SOC the following month. The veteran filed a substantive appeal in April 1995. Subsequently, SSOC's were issued in June and August 1995, March and August 1996, January 1997, and April 1999. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. A discharge summary from the New Hanover Memorial Hospital, dated in April 1984, noted diagnoses of acute inferior myocardial infarction, chronic obstructive lung disease, and ventricular arrhythmia. 3. On VA examination in September 1997, the veteran reported that he was not experiencing chest pain on exertion and had been asymptomatic, without further cardiac symptoms. Upon clinical evaluation at that time, the heart was normal in size and sound except for a grade-I systolic blowing murmur in the second interspace; there was no pedal edema, no evidence of congestive heart failure, no indication of circulatory problems, and no evidence of phlebitis in the left lower extremity. 4. The claim for benefits under the provisions of 38 U.S.C.A. § 1151 for a heart disorder is not plausible under the law, as there is no competent medical evidence that any claimed additional disability resulted from VA hospitalization, or from VA medical or surgical treatment. 5. A treatment record from the VA Medical Center (VAMC) in Fayetteville, dated in March 1996, noted that the veteran wore a brace on his left knee, and that the knee had a full range of motion without ligament laxity; a radiographic study revealed moderate degenerative joint disease. 6. On VA examination in September 1997, the veteran's left knee joint was markedly hypertrophied without specific swelling or tenderness, extension was limited to 10 degrees, flexion was to 140 degrees with mild muscle spasm and pain, and the McMurray and Drawer signs were negative. 7. The veteran's left knee disorder is not productive of extension limited to 30 degrees or limited to 45 degrees. 8. On VA examination in September 1997, evaluation of the veteran's right knee revealed mild hypertrophy of the joint but no swelling, tenderness, deformity, limitation of motion, or abnormality; an associated X-ray study reported minimal medial compartment joint space narrowing. 9. The veteran's right knee disorder does not exhibit evidence of occasional incapacitating exacerbations. CONCLUSIONS OF LAW 1. The claim for benefits for a heart disorder, under the provisions of 38 U.S.C.A. § 1151, is not well grounded. 38 U.S.C.A. §§ 1151, 5107(a) (West 1991); 38 C.F.R. § 3.358 (1999). 2. The schedular criteria for an increased rating greater than 30 percent for a left knee disorder have not been met. 38 U.S.C.A. § 1155, 5107 (West 1991); 38 C.F.R. § 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5261 (1999). 3. The schedular criteria for an increased rating greater than 10 percent for a right knee disorder have not been met. 38 U.S.C.A. § 1155, 5107 (West 1991); 38 C.F.R. § 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5010 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Basis A review of the veteran's claims file reflects that he was service connected for traumatic arthritis of the left knee in January 1964. The veteran was noted to have suffered a twisting of his left knee in service, and had complained of left knee pain since that time. In November 1963, he had undergone a surgical procedure at the VA hospital in Lake City, FL, for exploration of his left knee and removal of his left medial meniscus. A final discharge diagnosis from that facility included traumatic arthritis, minimal, left knee, residual of old injury, World War II, treated, improved; detached medial meniscus, left knee, secondary to old injury, treated, improved; and thrombophlebitis, minimal, left leg, treated, and improved. Subsequent VA examinations of the veteran were performed in August 1964 and August 1968. The first revealed no instability of the left knee. The second noted lateral laxity when the joint was manipulated under pressure. In July 1973, the RO received a statement from Walter Weis, M.D., dated that same month. Dr. Weis noted that the veteran suffered from a chronic condition that centered around lax ligaments in his left knee. This produced frequent giving- way, and constant abnormal motion of the knee joint when walking or running. This abnormal motion, Dr. Weis indicated, had produced gross abnormal wear in the left knee joint, resulting in moderately advanced degenerative hypertrophic osteoarthritis. Dr. Weis noted, in addition, that the veteran's left knee joint continued to function quite well, which was evidenced by the lack of any joint effusion. However, he believed that, over the coming years, the left knee joint would deteriorate quite rapidly. Dr. Weis also recommended that the veteran's left knee be stabilized with a Lenox Hill derotation brace. On VA examination in August 1973, a radiographic report of the veteran's left knee revealed narrowing of the joint space, suggestive of degenerative arthritis. A VA examination in December 1975 noted hypertrophic arthritic changes in both knees. The examiner further opined that the veteran's left knee disorder caused excessive weight to be thrown on the right knee, causing the development of traumatic arthritis in that joint. In an April 1976 rating decision, the RO service connected the veteran for a right knee disorder, as secondary to his service-connected left knee disorder. A subsequent VA examination of the veteran, in September 1977, revealed no medial lateral instability in the left knee, with X-ray findings of moderate degenerative arthritis in the left knee and mild degenerative arthritis in the right knee. On VA examination in April 1981, there was a full range of motion of both the veteran's knees. In addition, there was slight laxity of the medial collateral ligament of the left knee and of the lateral collateral ligament of the right knee. Radiographic studies revealed mild marginal spurring of the left knee, and slight marginal spurring of the right knee, consistent with degenerative joint disease. In April 1984, the veteran submitted a VA Form 21-4138 (Statement in Support of Claim) to the RO, in which he reported that, following surgery to his left knee in 1963, he had developed phlebitis of the left leg, and blood poisoning. The veteran also reported that in April 1984, a blood clot had damaged his heart, and that he had been told by his treating physician at that time that the blood clot and phlebitis were related to the surgery on his service- connected left knee in 1963. In May 1984, the RO received New Hanover Memorial Hospital treatment records, dated in April 1984. In particular, a medical record and discharge summary, which noted the attending physician as being Robert Hutchins, M.D., indicated that the veteran had been admitted to the hospital with complaints of retrosternal chest pain, associated with a faint feeling and near syncope. The veteran's family reported that he smoked three packs of cigarettes a day. A chest X-ray showed mild interstitial fibrosis with flattening of the diaphragm consistent with emphysema. An EKG (electrocardiogram) revealed ST (sinus tachycardia) segment elevation in the inferior leads, with ST segment depression in the anterior precordial leads, consistent with acute inferior wall myocardial infarction. The veteran developed some ventricular ectopy with several brief asymptomatic episodes of ventricular tachycardia. He also had one brief episode of bradycardia, with a rate of 30 beats per minute, but remained hemodynamically stable and asymptomatic at that time. He was started on Xylocaine IV and oral Quinidine, and was also given Streptokinase for attempts at coronary thrombolysis. Furthermore, the discharge summary subsequently noted that the veteran's arrhythmias ceased and he had no further problems with ventricular ectopy or bradycardia during the remainder of his hospital stay. In addition, his chest pain subsided within several hours after being given IV Nitroglycerin as well as Streptokinase, and he experienced no further chest pain while in the hospital. The veteran was subsequently placed on the myocardial infarction rehabilitation program (MIRP) and taken through level-7 activity, with absolutely no symptoms or complications. The summary noted a discharge diagnosis of acute inferior myocardial infarction, chronic obstructive lung disease, and ventricular arrhythmia. In December 1986, the RO received VAMC Fayetteville treatment records, dated from June 1984 to October 1985. These records noted the veteran's complaints of bilateral knee pain, and treatment for a heart condition. In particular, a discharge summary, dated from May to June 1984, noted a diagnosis of arteriosclerotic heart disease, recent inferior wall myocardial infarction, and mild congestive heart failure. The summary indicated that the veteran had been admitted giving a vague history of experiencing slight dizziness upon getting up from a recumbent position, and having a foggy feeling of his eyes. An initial chest X-ray suggested congestive heart failure, but a later X-ray during the veteran's hospitalization was normal. In addition, it was noted that a report in the veteran's chart showed that he had normal left ventricular motion, with no evidence of intracardiac thrombi. In March 1990, the veteran submitted a Statement in Support of Claim to the RO, in which he contended that, as a result of his thrombophlebitis, he had developed a blood clot in his left lower extremity, which eventually went to his heart, damaging the heart valves and causing his myocardial infarction. In addition, the veteran submitted New Hanover Memorial Hospital treatment records, dated from April 1984 to December 1984. In particular, a discharge summary, dated in November 1984, noted discharge diagnoses to include history of myocardial infarction, history of syncope likely related to complex ventricular ectopy, and history of left lower extremity deep venous thrombosis. Thereafter, in May 1994, the veteran requested that his service-connected bilateral knee disorder be re-evaluated. He reported that his bilateral knee disability required him to ambulate with the use of a cane. A VA Form 21-8678 (Application for Annual Clothing Allowance), dated in June 1994, noted that the veteran wore metal and fiber (elastic) braces on both his knees. In August 1994, the RO received VAMC Fayetteville medical records, dated from March 1993 to May 1994. In pertinent part, these records noted the veteran's treatment for his bilateral knee disorder and heart disorder. The veteran's heart disorder was reported to be doing well with medication. In September 1994, the veteran was medically examined for VA purposes. He reported a dull, aching pain in both knees aggravated by standing, walking, or stair climbing. On clinical evaluation, the left knee evidenced a limited range of motion with flexion to 110 degrees and extension to -10 degrees. There was mild joint effusion in the left knee joint. There was a loss in circumference of the left thigh and calf musculature. The right knee was reported as evidencing a normal external appearance, with a full range of motion. A radiographic study of both knees reflected post- traumatic osteoarthritic changes. In an October 1994 rating decision, the RO denied the veteran's increased rating claim for a bilateral knee disorder. The veteran filed an NOD in February 1995, in which he reported that his bilateral knee disorder had become so severe that he could only walk short distances which restricted his ability to conduct normal daily activities. In a subsequent VA Form 9 (Appeal to the Board of Veterans' Appeals), dated in March 1995, the veteran reported that he had been told by a VAMC Fayetteville physician that his left knee was gone, and that his options were a left above the knee amputation, left knee replacement, or to suffer with the pain. The veteran also reported that his left and right knees caused him constant pain and were unstable, requiring him to use a cane and/or knee braces. Thereafter, the RO received VAMC Fayetteville medical records, dated from May 1994 to April 1995. In particular, a treatment record, dated in April 1995, noted the veteran's complaints of occasional chest pain relieved by nitroglycerin tablets. The examiner also noted that the veteran was in obvious discomfort from knee pain on ambulation. A treatment record, dated in December 1994, noted on evaluation, that both the veteran's knees were without effusion, had a full range of motion, were negative for Lockman's and McMurray's testing, and evidenced subpatellar crepitus. Radiographic studies revealed early degenerative joint disease in the right knee, and severe degenerative joint disease in the left knee. In August 1995, the RO received VAMC Fayetteville medical records, most duplicative, dated from December 1994 to August 1995. In particular, a treatment record, dated in August 1995, noted the veteran walked with a cane. It was also noted that the veteran's heart had a regular rhythm and rate, a normal S1-S2 (first and second heart sounds), and there was no jugular venous distention. In September 1995, the veteran submitted a Statement in Support of Claim to the RO, in which he contended that in 1984 he had had a recurrence of phlebitis which resulted in a blood clot, and that this had subsequently ruined his heart valves. The veteran noted that since, he contracted phlebitis while in a VA hospital for surgery on his left leg, he should be granted service connection for a heart disorder. In October 1995, the RO received medical records from Martin Conley, M.D., some duplicative, dated from October 1984 to September 1995. In particular, a New Hanover Memorial Hospital discharge summary, dated in December 1987, noted that the veteran had undergone a cardiac catheterization which had revealed mildly decreased overall left ventricular contractility with severe septal akinesia and dyskinesia, with aneurysm formation of the infrabasilar portion of the ventricle. There was also 2+/mild mitral regurgitation. In addition, testing revealed one-vessel coronary artery disease, with 75 percent stenosis of a large anterolateral branch of the left anterior descending coronary artery and insignificant disease involving the right coronary artery. In was felt that a 50-percent lesion in the distal right coronary artery proximal to the posterior descending branch had likely been totally occluded at the time of the veteran's prior inferior myocardial infarction, with subsequent spontaneous thrombolytic reperfusion. The discharge diagnosis was complex ventricular ectopy including nonsustained ventricular tachycardia; history of recurrent syncope, likely related to complex ventricular ectopy; history of inferior myocardial infarction, with catheterization documented single-vessel coronary artery disease; and type II-B lipid disorder. In addition, in an October 1989 treatment record, the veteran reported his past medical history to include phlebitis in 1963, which later recurred in 1984 and led to a pulmonary embolism. A discharge summary, also dated in October 1989, noted that the veteran had been admitted to New Hanover Memorial Hospital in April 1984, with an acute inferior myocardial infarction complicated by complex ventricular ectopy, including nonsustained ventricular tachycardia. Otherwise, the remaining treatment records noted that veteran, from a cardiovascular standpoint, remained stable. A particular treatment note, dated in December 1994, revealed the veteran not to have symptomatic palpitations to suggest further complex ventricular ectopy, and that there had been no recent chest pain to suggest angina. Also in October 1995, the RO received a medical record from New Hanover Medical Center, dated in June 1973. This record noted the veteran's treatment for ascending lymphangitis, i.e., blood poisoning, of the lower left leg. In a March 1996 rating action, the RO denied the veteran's claim of entitlement to benefits under 38 U.S.C.A. § 1151, for a heart disorder. In April 1996, the veteran submitted a statement to the RO, in which he reported that Dr. Hutchins had been his attending physician at New Hanover Regional Medical Center in 1984. The veteran also stated that his wife and daughter had been informed, by Dr. Hutchins, that a blood clot had entered the veteran's heart, and that it had originated in his leg. In June 1996, the RO received New Hanover Regional Medical Center treatment records, dated from October 1980 to March 1989. These records, some duplicative, noted the veteran's treatment for his heart disorder, including previously reported findings from a cardiac catheterization report and a discharge summary, the latter having been dictated by Dr. Hutchins. In July 1996, the RO received VAMC Fayetteville treatment records, some duplicative, dated from April 1995 to March 1996. These records noted the veteran's complaints and treatment for bilateral knee pain. In particular, a treatment record, dated in March 1996, noted that the veteran wore a brace on his left knee, and, on clinical evaluation, had a full range of motion with no ligament laxity. A radiographic study revealed moderate degenerative joint disease. In September 1996, the RO received Duke University Medical Center treatment records, dated from December 1987 to July 1989. These records noted the veteran undergoing electrophysiological studies, ambulatory ECG (electrocardiogram) analysis, and treadmill exercise tests. In particular, the veteran was found to have nonsustained ventricular tachycardia and a normal sinus rhythm. Furthermore, earlier complaints of syncope were noted to have resolved, and the veteran was reported to be doing well on a low dose of Propafenone. In August 1997, the RO received VAMC Fayetteville medical records, dated from April 1984 to May 1997. These records noted the veteran's treatment for his heart disorder and bilateral knee pain. A radiographic report, dated in March 1995, revealed focal degenerative spurring associated with both knees. There was significant joint space narrowing involving the lateral and medial compartments of the left knee, as well as the medial compartment of the right knee. No acute fractures or obvious dislocations were noted. A treatment note, dated in January 1997, reported the veteran to be ambulating well. A later treatment note, dated in May 1997, reported him to be ambulating slowly with a cane. In September 1997, the veteran was medically examined for VA purposes. He was noted to enter the examining office in a wheelchair. He reported that he suffered from bilateral knee pain that had become progressively worse, with chronic aching and severe pain aggravated by weight bearing. The veteran indicated that he was using crutches and a wheelchair for necessary extensive ambulation. The examiner noted that no information regarding explicit flare-ups or other aggravating factors could be elicited from the veteran. He was noted to take Naprosyn regularly, and used an elastic knee brace on his left knee for stability. On clinical evaluation, the left knee joint was markedly hypertrophied but showed no specific swelling or tenderness. Extension was limited to 10 degrees, but flexion was normal at 140 degrees, with mild muscle spasm and pain. The McMurray and Drawer signs were negative. Evaluation of the right knee revealed mild hypertrophy of the joint but no swelling, tenderness, deformity, limitation of motion, or abnormality. Associated X-ray studies revealed minimal medial compartment joint space narrowing in the right knee; and medial and lateral joint space narrowing, as well as osteophytosis consistent with moderate osteoarthritis, in the left knee. The examiner reported that he had the veteran walk back and forth in his office for 4 to 5 minutes, after which the veteran complained of severe bilateral knee pain and stated that he could no longer continue walking. Evaluation of the veteran's knees at this time revealed the same clinical findings as those reported earlier in the examination, except for slightly more muscle spasm on maximum flexion of the left knee. Furthermore, the examiner reported that the veteran avoided weight bearing and, to the extent that this could be tested, no additional clinical abnormality of an objective nature could be observed. The veteran was noted to have evidenced a decreased functional ability, in that he was unable to continue walking for more than five minutes during the examination. In addition to his knee examination, the veteran also underwent a VA examination for his heart. The examiner noted the veteran's medical history, and that his claims file showed particularly that the previous myocardial infarction was apparently complicated by subsequent episodes of syncope with tachycardia, and physical findings had also revealed a murmur in the left second interspace of grade I intensity. The veteran reported that, since his myocardial infarction, he had been taking Verapamil, and had not experienced chest pain on exertion, and had been asymptomatic without further cardiac symptoms. On clinical evaluation, the heart was normal in size and sound except for a grade-I systolic blowing murmur in the second interspace. The examiner found no pedal edema, evidence of congestive heart failure, circulatory problems, or evidence of phlebitis in the left lower extremity. In addition, pulses were normal, and the veteran's blood pressure was 168/88. The examiner's clinical diagnosis was history of coronary artery disease, NYHA (New York Heart Association) classification I, with abnormal EKG and normal chest X-ray; and history of recurrent phlebitis of the left leg with normal clinical findings on evaluation. In addition, the examiner noted that, after consulting with other medical doctors, it was his opinion that the veteran's phlebitis, an episode of which may have occurred at the time of his myocardial infarction, would not be considered the cause of his myocardial infarction. In so finding, the examiner noted that, if a clot from the left leg had ascended into the circulatory system at the time, it would have caused a pulmonary embolus rather than a myocardial infarction. II. Analysis A. Benefits under 38 U.S.C.A. § 1151 The statutory criteria applicable to this case appear at 38 U.S.C.A. § 1151 (West 1991), which provides that, if a veteran suffers an injury or an aggravation of an injury as a result of VA hospitalization or medical or surgical treatment, not the result of the veteran's own willful misconduct, and the injury or aggravation results in additional disability or death, then compensation, including disability, death, or dependency and indemnity compensation, shall be awarded in the same manner as if the additional disability or death were service-connected. See 38 C.F.R. § 3.358(a), 38 C.F.R. § 3.800(a) (1999). The regulations provide that, in determining whether additional disability exists, the veteran's physical condition immediately prior to the disease or injury upon which the claim for compensation is based will be compared with the physical condition subsequent thereto. With regard to medical or surgical treatment, the veteran's physical condition prior to the disease or injury is the condition which the medical or surgical treatment was intended to alleviate. Compensation is not payable if the additional disability or death results from the continuance or natural progress of the disease or injury for which the training, treatment, or hospitalization was authorized. 38 C.F.R. § 3.358(b)(1), (2). In addition, the regulations specify that the additional disability or death must actually result from VA hospitalization or medical or surgical treatment, and not merely be coincidental therewith. In the absence of evidence satisfying this causation requirement, the mere fact that aggravation occurred will not suffice to make the additional disability or death compensable. 38 C.F.R. § 3.358(c)(1), (2). The regulations further provide that compensation is not payable for the necessary consequences of medical or surgical treatment properly administered with the express or implied consent of the veteran, or, in appropriate cases, the veteran's representative. "Necessary consequences" are those which are certain to result from, or were intended to result from, the medical or surgical treatment provided. Consequences otherwise certain or intended to result from a treatment will not be considered uncertain or unintended solely because it had not been determined, at the time consent was given, whether that treatment would in fact be administered. 38 C.F.R. § 3.358(c)(3). Finally, if the evidence establishes that the proximate cause of the injury suffered was the veteran's willful misconduct or failure to follow instructions, the additional disability or death will not be compensable, except in the case of a veteran who is incompetent. 38 C.F.R. § 3.358(c)(4). So as to avoid any misunderstanding as to the governing law, the Board notes that earlier interpretations of the statute, embodied in regulations, required evidence of negligence or other fault on the part of VA, or the occurrence of an accident or an otherwise unforeseen event, to establish entitlement to benefits under 38 U.S.C.A. § 1151. See 38 C.F.R. § 3.358(c)(3) (1994). Those provisions were invalidated by the United States Court of Appeals for Veterans Claims (formerly known as the United States Court of Veterans Appeals) in the case of Gardner v. Derwinski, 1 Vet.App. 584 (1991). That decision was affirmed by both the United States Court of Appeals for the Federal Circuit, in Gardner v. Brown, 5 F.3d 1456 (Fed. Cir. 1993), and the United States Supreme Court, in Brown v. Gardner, 513 U.S. 115, 115 S. Ct. 552 (1994). In March 1995, the Secretary of Veterans Affairs published an interim rule amending 38 C.F.R. § 3.358 to conform with the Supreme Court decision. The amendment was made effective November 25, 1991, the date the initial Gardner decision was issued by the Court of Appeals for Veterans Claims. 60 Fed. Reg. 14,222 (Mar. 16, 1995). The interim rule was later adopted as a final rule, 61 Fed. Reg. 25,787 (May 23, 1996), and codified at 38 C.F.R. § 3.358(c) (1998). Subsequently, Congress amended 38 U.S.C.A. § 1151, effective for claims filed on or after October 1, 1997, to preclude compensation in the absence of negligence or other fault on the part of VA, or an event not reasonably foreseeable. Pub. L. No. 104-204, § 422(a), 110 Stat. 2926 (Sept. 26, 1996), codified at 38 U.S.C.A. § 1151 (West Supp. 1997); see also VAOPGCPREC 40-97 (Dec. 31, 1997). As noted above, the veteran's claim for benefits under section 1151 for a heart disorder was filed in September 1995. Therefore, under the statute and the opinion of the General Counsel cited above, this claim has been adjudicated by the RO, and is being reviewed by the Board, under the version of 38 U.S.C.A. § 1151 extant before the enactment of the statutory amendment, as interpreted in the Gardner decisions, supra, and under the interim rule issued by the Secretary on March 16, 1995, and adopted as a final regulation on May 23, 1996. Thus, neither VA fault nor an event not reasonably foreseeable would be required for this claim to be granted. However, a claimant seeking benefits under any law administered by the Secretary of Veterans Affairs has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. If the claim is well grounded, the Secretary is obligated to assist a claimant in developing evidence pertaining to the claim. 38 U.S.C.A. § 5107(a). If the claim is not well grounded, there is no duty to assist. Epps v. Brown, 9 Vet.App. 341 (1996), aff'd sub nom. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998); Murphy v. Derwinski, 1 Vet.App. 78 (1990). Thus, the threshold question for any claim, including one filed under the provisions of 38 U.S.C.A. § 1151, is whether the claimant has presented a well-grounded claim. See Elkins v. West, 12 Vet.App. 209, 213 (1999) (en banc), citing Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table), and Epps, supra. See also Morton v. West, 12 Vet.App. 477, 480 (1999) (noting that the Federal Circuit, in Epps v. Gober, supra, "rejected the appellant's argument that the Secretary's duty to assist is not conditional upon the submission of a well-grounded claim"). A well-grounded claim is one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive, but only plausible, to satisfy the initial burden of 38 U.S.C.A. § 5107(a). Murphy, supra. To present a well grounded claim, the claimant must provide evidence; mere allegation is insufficient. Tirpak v. Derwinski, 2 Vet.App. 609 (1992). The evidence the claimant must provide must be sufficient to justify a belief by a fair and impartial individual that the claim is plausible. Lathan v. Brown, 7 Vet.App. 359 (1995). Where the determinative issue is factual in nature, competent lay evidence may suffice. Gregory v. Brown, 8 Vet.App. 563 (1996). Where the determinative issue involves medical etiology or diagnosis, medical evidence is required. Lathan, supra. The Court of Appeals for Veterans Claims has recently held that the requirements for a well-grounded claim under section 1151 are, paralleling those generally set forth for establishing other service-connection claims, as follows: (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of incurrence or aggravation of a disease or injury as the result of hospitalization, medical or surgical treatment, or the pursuit of a course of vocational rehabilitation under chapter 31 of title 38, United States Code; and (3) medical evidence of a nexus (i.e., a link or a connection) between that asserted injury or disease and the current disability. In addition, the Court has determined that an appellant's claim would also generally be well grounded, with respect to the continuity-of-symptomatology analysis under 38 C.F.R. § 3.303(b), if he or she submitted evidence of each of the following: (a) evidence that a condition was "noted" during his/her VA hospitalization or treatment; (b) evidence showing continuity of symptomatology following such hospitalization or treatment; and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post- hospitalization/treatment symptomatology. See Jones v. West, 12 Vet.App. 460, 464 (1999). Therefore, a claim for benefits under the provisions of 38 U.S.C.A. § 1151 must be supported by medical evidence of additional disability that resulted from VA hospitalization, or medical or surgical treatment. See Boeck v. Brown, 6 Vet.App. 14, 16-17 (1993), and Ross v. Derwinski, 3 Vet.App. 141, 144 (1992), holding that a veteran must submit evidence sufficient to well ground a claim for benefits under 38 U.S.C.A. § 1151. See also Jimison v. West, 13 Vet.App. 75, 77-78 (1999). The veteran has contended that as a result of surgery on his left knee at a VA medical facility in 1963, he developed thrombophlebitis. He claims the disorder recurred in 1984 and he developed a blood clot, which subsequently damaged his heart valves and caused his myocardial infarction and ventricular arrhythmia. Upon review of the evidence of record, the Board finds that the veteran has not submitted a well-grounded claim for benefits under 38 U.S.C.A. § 1151, for a heart disorder. In reviewing the evidence, we are cognizant that the veteran developed minimal thrombophlebitis of the left leg following left knee surgery in November 1963. The condition at discharge was noted to have been treated and improved. In April 1984, he was admitted to New Hanover Memorial Hospital with complaints of retrosternal chest pain associated with a faint feeling and near syncope. Dr. Hutchins noted that the veteran was to be given Streptokinase for attempts at coronary thrombolysis. A discharge summary noted diagnoses of acute inferior myocardial infarction, chronic obstructive lung disease, and ventricular arrhythmia. Thrombolysis is defined as the breaking up of a thrombus. Thrombus is defined as a blood clot that obstructs a blood vessel or a cavity of the heart. See Taber's Cyclopedic Medical Dictionary 1730, 1732 (15th ed. 1985). In reviewing Dr. Hutchin's treatment and discharge summaries, we find no clinical evidence that the veteran was suffering from thrombophlebitis at the time of his hospitalization for a myocardial infarction in 1984. We also find no clinical evidence that a blood clot entered the veteran's heart. However, even if we assume that a blood clot did enter the veteran's circulatory system and lodged in his heart, based on attempts at coronary thrombolysis by Dr. Hutchins, there is no clinical evidence that it caused his myocardial infarction, ventricular arrhythmias, or damaged the veteran's heart valves. We also note that subsequent treatment records and discharge summaries from the VAMC Fayetteville and New Hanover Memorial Hospital do not report that the veteran's myocardial infarction or arrhythmias were the result of a blood clot. The veteran was noted to have suffered from arteriosclerotic heart disease, recent inferior wall myocardial infarction, and mild congestive heart failure. Furthermore, on VA examination in September 1997, the veteran reported that he was not experiencing chest pain on exertion and had been asymptomatic, without further cardiac symptoms. On clinical evaluation, the heart was normal in size and sound except for a grade-I systolic blowing murmur in the second interspace, and there was no pedal edema, no evidence of congestive heart failure, no circulatory problems, and no evidence of phlebitis in the left lower extremity. The examiner noted that, after consultation with other physicians, it was his opinion that, if a clot from the left leg had ascended into the circulatory system at that time, it would have caused a pulmonary embolus, and not the veteran's myocardial infarction. While the law applicable to this case, as discussed above, exempts the veteran from a requirement to establish negligence or other wrongdoing on the part of VA, the law does require proof of causation; in other words, any claimed additional disability must be shown, by medical evidence, to have resulted from, and not merely to have been coincidental with, the VA hospitalization or medical or surgical treatment. The medical evidence of record does not reflect that a blood clot resulted from VA hospitalization or medical or surgical treatment, or that a blood clot caused the veteran any additional disability. As noted above, the veteran's cardiac condition is stable and otherwise asymptomatic. Thus, under the law, the veteran must provide medical-nexus evidence to well ground his claim, and he has not done so. Therefore, the only evidence supporting the veteran's assertion that he sustained additional disability as a result of VA hospitalization or medical or surgical treatment consists of his own statements to that effect. However, he is not shown to possess the technical competence to establish such a relationship. As discussed above, a claim based upon an assertion as to cause-and-effect relating to a particular disability requires competent medical evidence in order to be well grounded. The Court has reiterated this requirement many times. See, e.g., Voerth v. West, 13 Vet. App. 117, 120 (1999) ("Unsupported by medical evidence, a claimant's personal belief, no matter how sincere, cannot form the basis of a well-grounded claim."); Bostain v. West, 11 Vet.App. 124, 127 (1998) ("lay testimony . . . is not competent to establish, and therefore not probative of, a medical nexus"); Routen v. Brown, 10 Vet.App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). See also Espiritu v. Derwinski, 2 Vet.App. 492 (1992); Moray v. Brown, 5 Vet.App. 211 (1993); Grottveit v. Brown, 5 Vet.App. 91 (1993). Moreover, as sympathetic as we might be toward the veteran's condition, the Board is not permitted to reach medical determinations without considering independent medical evidence to support our findings, and must cite to competent evidence of record to support our conclusions. See Rucker v. Brown, 10 Vet.App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet.App. 171 (1991), and Hatlestad v. Derwinski, 3 Vet.App. 213 (1992). Having reviewed the medical records in this case, we can find none supporting the veteran's contentions that he incurred any additional disability as a result of VA hospitalization, or medical or surgical treatment. Accordingly, it is the Board's conclusion that the veteran has failed to present evidence sufficient to justify a belief by a fair and impartial individual that his claim for compensation under 38 U.S.C.A. § 1151 is well grounded, as required by 38 U.S.C.A. § 5107(a) (West 1991), and, therefore, the claim must be denied. B. Increased Rating for Knees The veteran has submitted well-grounded claims for increased ratings within the meaning of 38 U.S.C.A. § 5107(a). See Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990); Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). That is, the Board finds that he has submitted claims which are plausible. This finding is based on the veteran's assertion that his service- connected left and right knee disorders are more severe then previously evaluated. See Jackson v. West, 12 Vet.App. 422, 428 (1999), citing Proscelle v. Derwinski, 2 Vet.App. 629 (1992). The Board is also satisfied that all relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained, and that no further assistance is required to comply with the duty to assist, as mandated by 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings which is based upon average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. §§ 3.102, 4.3, 4.7 (1999). Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet.App. 55, 58 (1994); 38 C.F.R. §§ 4.1, 4.2 (1999). The veteran's residuals of a left knee disorder, with traumatic arthritis, has been assigned a 30 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5257. Under this code, for impairment of the knee, severe recurrent subluxation or lateral instability warrants a 30 percent rating. This is the highest disability rating under this Code. The veteran's arthritis of the right knee has been assigned a 10 percent rating under 38 C.F.R. § 4.71a, DC 5010, which is provided for, "Degenerative arthritis." Under this regulatory scheme, evaluations are based upon limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the criteria for a compensable evaluation for limitation of motion are not met, a 10 percent evaluation is assigned for each major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is no evidence of limitation of motion, a 10 percent evaluation is warranted for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent evaluation is warranted for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, and evidence of occasional incapacitating exacerbations. The Board notes that the decision as to which diagnostic code should be applied in a given case is for the RO and the Board. See Bierman v. Brown, 6 Vet.App. 125 (1994); Butts v. Brown, 5 Vet.App. 532 (1993) (en banc). However, the rationale for selecting a specific diagnostic code must be explained. Lendenmann v. Principi, 3 Vet.App. 345 (1992); Pernorio v. Derwinski, 2 Vet.App. 625 (1992). With respect to the left knee, the Board is cognizant that a VAMC Fayetteville treatment record, dated in March 1996, noted that the veteran wore a knee brace on his left knee, and that the knee had a full range of motion without ligament laxity. On VA examination in September 1997, the veteran reported that he had difficulty walking due to severe pain, and that he used a wheel chair and cane. The examiner found the left knee joint was markedly hypertrophied but did not exhibit specific swelling or tenderness. Extension was limited to 10 degrees but flexion was normal at 140 degrees, with mild muscle spasm and pain. McMurray and Drawer signs were negative. Following a walk in the examination room for 4 to 5 minutes, subsequent examination of the veteran's left knee revealed the same clinical findings as reported earlier during the examination, except for an increase in muscle spasm of the left knee on maximum flexion. Given that the most recent medical evidence reflects pain and limitation of extension of the left knee, without limitation of flexion or ligament laxity, the Board concludes that the veteran's left knee disorder is more appropriately evaluated under DC 5261, for limitation of extension of the leg. Under this Code, limitation of extension of the leg warrants a 50 percent evaluation at 45 degrees, 40 percent at 30 degrees, 30 percent at 20 degrees, 20 percent at 15 degrees, 10 percent at 10 degrees, and noncompensable at 5 degrees. 38 C.F.R. § 4.71a, DC 5261 (1999). Thus, when we apply the most current evidence of record, which reflects a limitation of extension to 10 degrees, the veteran would necessarily warrant a 10 percent disability rating under DC 5261. However, in this instance, due to the fact that the veteran's left knee disability has been rated at 30 percent for more than 20 years, under the law, the rating can not be reduced, and therefore remains at 30 percent. See 38 C.F.R. § 3.951(b) (1999), "A disability that has been continuously rated at or above any evaluation of disability for 20 or more years for compensation purposes under laws administered by the Department of Veterans Affairs will not be reduced to less than such evaluation except upon a showing that such rating was based on fraud." We are cognizant that the veteran's representative has contended that the veteran's left knee disorder should have been considered in light of VAOPGCPREC 23-97, in which the VA General Counsel held that a claimant who has arthritis and instability of the knee could be rated separately under DC 5003 and DC 5257, based upon additional disability. In this instance, as noted above, given that the veteran's left knee shows a lack of ligament laxity, subluxation, or lateral instability, his service-connected disability is more appropriately rated under DC 5261, for limitation of extension of the leg. Thus, consideration of VAOPGCPREC 23- 97 is no longer applicable. In any event, the veteran is receiving a protected disability rating that allows for a higher rating than the evidence warrants under DC 5261, and therefore any additional pain as a result of the arthritis in his left knee is adequately compensated for with the additional 20 percent he is receiving. Several alternative DC's are also available for assessing residuals of knee injuries under 38 C.F.R. § 4.71a, and would allow for a higher disability rating. Under DC 5256, a 40 percent evaluation requires that the knee be fixed in flexion at an angle between 10 degrees and 20 degrees. A 50 percent evaluation requires that the knee be fixed at an angle between 20 degrees and 45 degrees. When there is extremely unfavorable ankylosis, which involves the knee in flexion at an angle of 45 degrees or more, a 60 percent evaluation is warranted. Under DC 5262, nonunion of the tibia and fibula, with loose motion, requiring a brace, warrants a 40 percent evaluation. As the clinical findings reflect, the veteran's left knee is not fixed in flexion and has a range of motion to 140 degrees. Furthermore, while the veteran wears a brace on his left knee, the knee does not evidence ligament laxity, and there is no evidence of nonunion of the tibia and fibula with loose motion. Therefore, the veteran does not warrant a higher evaluation under these alternative Codes. With respect to the veteran's right knee disorder, upon VA medical examination in September 1997, evaluation of the right knee revealed mild hypertrophy of the joint but no swelling, tenderness, deformity, limitation of motion, or abnormality. An associated X-ray study revealed minimal medial compartment joint space narrowing in the right knee. Therefore, while there is arthritic involvement of two major joints (left and right knee), the Board finds the veteran has not exhibited evidence of occasional incapacitating exacerbations to warrant an increase to 20 percent for his right knee disorder under DC 5003. The Board has also considered the applicability of the precedential judicial decision in DeLuca v. Brown, 8 Vet.App. 202, 207 (1995), wherein the Court held that a particular diagnostic code which rates on the basis of range of motion must be applied in conjunction with 38 C.F.R. §§ 4.40, 4.45, and the effects of pain and other symptoms on use, and of flare-ups, must be taken into account in rating the disability. As noted above, on VA examination in September 1997, the examiner reported that no information regarding explicit flare-ups or other aggravating factors could be elicited from the veteran. Furthermore, the examiner reported that the veteran avoided weight bearing and, to the extent that this could be tested, no additional clinical abnormality of an objective nature could be observed. The veteran was noted to have evidenced a decreased functional ability in that he was unable to continue walking for more than five minutes during the examination. We recognize the difficulty the examiner faced in attempting to anticipate the degree of additional disability which might be manifested outside the examination setting. In this instance, we are aware of the limited functionability of the veteran, as demonstrated by his use of a wheelchair and cane. However, we are also aware that the objective clinical findings do not necessarily reflect the severity claimed by the veteran for his bilateral knee disorder. As we stated previously, given that the veteran would only warrant a 10 percent disability rating under DC 5261 for his left knee disorder, we believe any additional pain or functional loss associated with his left knee disability is appropriately compensated for with the additional (protected) 20 percent rating he is receiving. With respect to the veteran's right knee, as to degenerative arthritis, DC 5003 rates not only on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved, but also as to pain when limitation of motion is not demonstrated. Thus, it is not clear whether the DeLuca holding applies in the present case. See Johnson v. Brown, 9 Vet.App. 7, 11 (1996), holding that sections 4.40 and 4.45 do not apply where a rating is not predicated on loss of range of motion. In this instance, the veteran's right knee has a normal range of motion, with no tenderness, swelling, or abnormality. Given these clinical findings, the Board finds the veteran's right knee is more analogously rated with respect to pain and not based on any limitation of motion. Therefore, sections 4.40 and 4.45 do not apply. Furthermore, even if we did consider 4.40 and 4.45, any pain or functional loss is adequately compensated for in the veteran's current 10 percent disability rating given that his right knee was shown to be essentially normal on clinical evaluation. The Board additionally notes that the veteran has reported being in receipt of Social Security Administration (SSA) disability benefits, apparently beginning sometime in 1973, as a result of his knees and back. We are aware that, "[w]hen VA is put on notice prior to the issuance of a final decision of the possible existence of certain records and their relevance, the BVA must seek to obtain those records." Hayes v. Brown, 9 Vet.App. 67, 73-74 (1996) (quoting Murincsak v. Derwinski, 2 Vet.App. 363, 373 (1992)). We note that the Court has never held that VA must, in knee-jerk fashion, obtain records of SSA disability determinations in every case. As the Court more recently stated in this regard, "[p]art of the Secretary's obligation is to review a complete record." Baker v. West, 11 Vet.App. 163, 169 (1998). Here, it appears clear that the records upon which the SSA reportedly granted the veteran disability benefits would not be relevant to determining the veteran's current level of disability, given that they are more than 25 years old. Thus, we find the record before us is complete, and to remand for the RO to request copies of those records from the SSA would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran. The Court has held that such remands are to be avoided. See Winters v. West, 12 Vet.App. 203, 207 (1999) (en banc); Soyini v. Derwinski, 1 Vet.App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). On the foregoing record, the Board concludes the criteria for an increased rating for the veteran's left knee disorder, greater than 30 percent, are not met; and that the criteria for an increased rating for a right knee disorder, greater than 10 percent, are not met. In reaching this decision, we have considered the potential application of the other various provisions of 38 C.F.R. Parts 3 and 4, whether or not they were raised by the veteran, as well as the entire history of the veteran's conditions as required by Schafrath v. Derwinski, 1 Vet.App. 589, 592 (1991). Furthermore, the Board finds in this case the evidence does not present an unusual disability picture so as to render impractical the application of the regular schedular standards and warrant consideration for referral for an extra-schedular evaluation under 38 C.F.R. § 3.321(b)(1) (such ratings may be authorized by the Under Secretary for Benefits or the Director of the Compensation and Pension Service). For example, the disabilities have not caused marked interference with employment or necessitated frequent hospitalization. See Shipwash v. Brown, 8 Vet.App. 218, 227 (1995), and Floyd v. Brown, 9 Vet.App. 94-96 (1996). ORDER 1. Entitlement to benefits under 38 U.S.C.A. § 1151 for a heart disorder, claimed to have resulted from treatment at a VA medical facility, is denied. 2. Entitlement to an increased rating for a left knee disorder is denied. 3. Entitlement to an increased rating for a right knee disorder is denied. ANDREW J. MULLEN Member, Board of Veterans' Appeals