Citation Nr: 0005874 Decision Date: 03/03/00 Archive Date: 03/14/00 DOCKET NO. 97-15 132 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an increased disability evaluation for service-connected traumatic arthritis, right (major) shoulder with history of dislocation and impingement syndrome, currently rated as 20 percent disabling. 2. Entitlement to an increased disability evaluation for service-connected traumatic arthritis, left (minor) shoulder, status post acromioplasty with history of dislocation and impingement syndrome, currently rated as 20 percent disabling. 3. Entitlement to service connection for a back disorder, on a direct basis and secondary to the veteran's service- connected bilateral shoulder disorders. 4. Entitlement to service connection for a cervical spine disorder, on a direct basis and secondary to the veteran's service-connected bilateral shoulder disorders. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD W. Yates, Associate Counsel INTRODUCTION The appellant served on active duty from April 1971 to April 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 1997 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. That rating decision, in pertinent part, denied the appellant's claims for: (1) an increased disability evaluation, in excess of 20 percent, for service- connected traumatic arthritis, right (major) shoulder with history of dislocation and impingement syndrome; (2) an increased disability evaluation, in excess of 20 percent, for traumatic arthritis, left (minor) shoulder, status post acromioplasty with history of dislocation and impingement syndrome; (3) service connection for a back disorder, claimed on a direct basis and secondary to the appellant's service- connected bilateral shoulder disorders; and (4) service connection for a cervical spine disorder, claimed on a direct basis and secondary to the appellant's service-connected bilateral shoulder disorders. The appellant filed a timely notice of disagreement and substantive appeal pertaining to all of these issues. The case was previously before the Board in March 1999, when it was remanded for examination of the appellant and medical opinions. The requested development has been completed. The Board now proceeds with its review of the appeal. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal. 2. The veteran's service-connected traumatic arthritis, right (major) shoulder with history of dislocation and impingement syndrome, is currently manifested by: forward flexion to 90 degrees; abduction to 90 degrees; internal rotation to 90 degrees; external rotation to 90 degrees; no swelling or effusion; no tenderness; no weakness or evidence of atrophy; no evidence of instability; no motor weakness or sensory deficits in the upper extremities; active deep tendon reflexes; and subjective complaints of pain on motion. X-ray examination revealed a small osteophyte on the inferior aspect of the lateral end of the clavicle. 3. The veteran's service-connected traumatic arthritis, left shoulder, status post acromioplasty with history of dislocation and impingement syndrome, is currently manifested by: forward flexion to 110 degrees; abduction to 110 degrees; internal rotation to 30 degrees; external rotation to 90 degrees; no swelling or effusion; no deformity or discoloration; no evidence of instability; no crepitation, atrophy, deformity or evidence of weakness; no motor weakness or sensory deficits in the upper extremities; active deep tendon reflexes; and subjective complaints of pain on motion. X-ray examination revealed a small osteophyte on the inferior aspect of the humoral head with slight narrowing of the articular cartilage at the glenohumeral joint. 4. The veteran is presently service-connected for: (1) traumatic arthritis, right shoulder with history of dislocation and impingement syndrome; and (2) traumatic arthritis, left shoulder, status post acromioplasty with history of dislocation and impingement syndrome. 5. The medical evidence does not establish the plausibility of a nexus or a possible cause-and-effect relationship or aggravation between the veteran's service-connected disabilities and his current cervical spine disorder or his current back disorder. 6. The veteran's service medical records do not show a chronic cervical spine or back disorder having been incurred or aggravated during the veteran's active duty service. His discharge examination, dated in April 1973, noted that his back and neck were normal. 7. The earliest post service medical records relating to treatment of a cervical spine or back disorder occurred in 1996, 23 years after the veteran's discharge from active duty service. 8. There is no competent evidence linking the veteran's current cervical spine disorder or his current back disorder to his active duty military service. 9. The veteran has not presented a plausible claim for service connection for either a cervical spine disorder or a back disorder. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for service-connected traumatic arthritis, right (major) shoulder with history of dislocation and impingement syndrome, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, 4.1, 4.2, 4.3, 4.7, 4.27, 4.40, 4.45, and 4.71a, Diagnostic Codes 5010-5201 (1999). 2. The criteria for a disability rating in excess of 20 percent for service-connected traumatic arthritis, left (minor) shoulder, status post acromioplasty with history of dislocation and impingement syndrome, have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4, 4.1, 4.2, 4.3, 4.7, 4.27, 4.40, 4.45, and 4.71a, Diagnostic Codes 5010-5201 (1999). 3. The veteran has not presented a well-grounded claim for service connection for a back disorder, on a direct basis and secondary to the veteran's service-connected bilateral shoulder disorders. 38 U.S.C.A. §§ 101(16), 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.310(a) (1999). 4. The veteran has not presented a well-grounded claim for service connection for a cervical spine disorder, on a direct basis and secondary to the veteran's service-connected bilateral shoulder disorders. 38 U.S.C.A. §§ 101(16), 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.310(a) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background The veteran served on active duty in the United States Army from April 1971 to April 1973. The RO has retrieved his service medical records and they appear to be complete. The veteran's entrance examination, dated in September 1970, noted essentially normal findings throughout. An inservice treatment report, dated in March 1972, noted the veteran's history of left shoulder pain for the past six months. X-ray examination of the left shoulder revealed a small defect of the posterior humoral head. The report concluded with an assessment of probable subluxation of the humoral head. A May 1972 treatment report noted the veteran's complaints of continuing left shoulder pain. The report concluded with an impression of historical evidence of subluxation of left shoulder, none at present. An orthopedic consultation report, dated in June 1972, noted that no instability of the left shoulder could be demonstrated. X-ray examination of the left shoulder was also noted as negative. In June 1972, the veteran sought treatment for low back pain. Physical examination revealed hard muscles, bilaterally, in the lower back. The veteran was prescribed a heating pad for treatment. In October 1972, the veteran injured his left shoulder during a basketball game. X-ray examination of the left shoulder was negative. The report concluded with an impression of muscle strain. A subsequent treatment report, dated in October 1972, noted that the veteran had fallen down stairs and dislocated his right shoulder. X-ray examination of the right shoulder was negative. The report concluded with a diagnosis of probable anterior dislocation and spontaneous reduction, right shoulder. In December 1972, the veteran sought treatment for complaints of low back pain after heavy lifting. The treatment report indicated that the veteran was unable to touch his toes. An impression of lumbar strain was given and the veteran was prescribed pain medication. No follow-up treatment was indicated. In April 1973, the veteran's discharge examination was conducted. The report of this examination noted that the veteran's upper extremities, neck and spine were normal. A medical history taken at that time indicated that he did not have back trouble of any kind. In April 1975, the veteran filed an Application for Compensation or Pension, VA Form 21-526, seeking service connection for bilateral shoulder disorders. No reference to any neck or back disorders was indicated. In September 1975, a VA general physical examination was conducted. The report of this examination noted the veteran's complaints of frequent bilateral shoulder dislocation. No complaints of back or neck pain was indicated. The examination report concluded with a diagnosis of history of recurrent dislocation, both shoulders, with clinical evidence of residual capsular laxity found on physical examination. Medical treatment reports, from February 1991 to April 1999, were retrieved from the VA medical center in Jackson, Mississippi. A review of these records revealed treatment for a variety of conditions. A March 1991 treatment report noted the veteran's complaints of bilateral shoulder pain. An orthopedic consultation, dated in April 1991, noted an assessment of mild left shoulder impingement syndrome. In June 1991, a VA orthopedic examination was conducted. The report of this examination noted the veteran's complaints of bilateral shoulder pain. Physical examination revealed no instability of either shoulder. The report also noted that "[t]here was no evidence of atrophy of either deltoid." X- ray examination revealed mild arthritic changes involving right and left acromioclavicular joints. No other significant abnormalities were indicated. The report concluded with diagnoses of: (1) residuals of dislocation of left shoulder with probable impingement syndrome; (2) residuals of dislocation of right shoulder with probable mild impingement syndrome; and (3) arthritic changes of both acromioclavicular joints. In August 1992, a hearing was conducted before the RO. At the hearing, the veteran testified that he has a history of dislocated shoulders, bilaterally. He noted that he continues to have pain in his shoulders and that this condition limits him physically. In July 1994, a VA examination for joints was conducted. The report of this examination noted the veteran's narrative history of bilateral shoulder injuries/dislocations during service. The report noted that the veteran "is working on assembly, using medium-sized power tools, and has been working some eight years with a good record but some consideration for rest periods and so forth." The report concluded with an impression of "[s]ymptoms of traumatic arthritis of both shoulders with a marked apprehensive phenomenon and dominantly subjective features but difficulty in evaluating range of motion due to pain." A treatment report, dated in January 1996, noted the veteran's complaints of low back pain "since 1980's." An orthopedic consultation, dated in April 1996, noted the veteran's complaints of bilateral shoulder pain, left greater than the right. The veteran received instructions regarding the home exercise program. In June 1996, a magnetic resonance imagining examination of the veteran's cervical spine revealed what "appears to be relative thinning (in AP diameter) of the superior most aspect of the odontoid process. This is of uncertain etiology and suggests the possibility of pannus formation around the posterior aspect of the odontoid." The report also noted borderline spinal stenosis due to hypertrophic spurring and disc bulging at C3- C4, mild posterior bulging of the disc at L4-L5 and spinal stenosis due to disc protrusion and hypertrophic spurring at C5-C6. In July 1996, the veteran underwent an acromioplasty, left shoulder. A treatment report, dated in July 1996, noted that he was instructed on shoulder strengthening exercises. In October 1996, a VA examination for joints was conducted. The report of this examination noted that the veteran "works at an assembly station where power breakers are constructed." The report noted the veteran's complaints of "some pain" in the deltoid area and a limitation of motion in the left shoulder. It also noted intermittent aching pain, aggravated by movement, in the right deltoid area. Physical examination revealed: Left Shoulder: The patient has no evidence of swelling, atrophy or deformity. He is tender over the anterior lateral subdeltoid bursa. He has several well-healed arthroscopic portals. With complaints of pain, he has the following range of motion in the left shoulder: Flexion 160 degrees, extension 60 degrees, abduction 160 degrees, internal rotation 90 degrees, external rotation 90 degrees. In the right shoulder he has no swelling or deformity. He is tender over the anterior lateral subdeltoid bursa. He has slight crepitation with motion. He has the following range of motion, actively with complaints of pain at the extremes of motion: Flexion 160 degrees, extension 60 degrees, abduction 160 degrees, internal rotation 90 degrees, external rotation 90 degrees X-ray examination of the left shoulder revealed mild narrowing of the glenohumeral joint with some widening of the acromioclavicular joint. X-ray examination of the cervical spine revealed some degenerative disc disease at multiple levels. The report concluded with impression of: (1) status post arthroscopic acromioplasty of the distal left clavicle; (2) impingement syndrome, right shoulder; and (3) degenerative disc disease, cervical spine. In October 1996, the veteran was treated for lower back pain and numbness in the lower extremities for the past "several years." Physical examination of the back revealed mild pain to palpation at disc levels C5-T1. A follow-up treatment report, dated in October 1996, noted that the veteran was "seen for low back pain that had begun in the 1980's but increased in the past several months along with increasing cervical spine pain." The report noted that a magnetic resonance imaging examination had been performed and revealed findings of: a loss of height at the L5-S1 disc level; small to modest disc herniation centrally with mild flattening of the anterior aspect of the thecal sac and obliteration of the anteromedial epidural fat adjacent to the S1 nerve root on the right; and mild bilateral facet and ligamentum flavum hypertrophy at the L4-L5 disc level. X-ray examination of the spine revealed mild curvature of the lumbar spine with convexity towards the patient's left, well-maintained vertebral bodies, narrowing at the L5-S1 disc level and no significant spondylosis. The treatment report concluded that "[t]he shoulder problem is unrelated to the lumbar [and] cervical spine problem." In November 1996, an electromyography/nerve conduction velocity examination was conducted. The report of this procedure noted an impression of findings within normal limits. In December 1996, a VA examination for joints was conducted. The report of this examination noted the veteran's narrative history of falling out of a truck, injuring both of his shoulders, during his active duty service. As a result of this incident, the veteran claims that he developed severe, radiating back pain in the cervical and lumbar regions. The report also noted that "[h]is right shoulder aches anteriorly but does not swell as much. His left shoulder still aches anteriorly with some radiation into the posterior shoulder girdle, and he has pain in the left paracervical musculature." Physical examination revealed: The patient has limited range of motion in left shoulder with some anterior swelling and heat. It is still diffusely tender in the anterior aspect, posterior aspect and some radiation into the entire left upper quadrant. Right shoulder is slightly tender anteriorly. No atrophy. No radiation of pain today. C-spine is tender in the paraspinous muscles, left greater than right, with some tender points near the lateral aspect of C3, 4, 5, and 6. The report concluded with an impression of: (1) traumatic arthritis probably of both shoulders, left greater than right with ongoing synovitis; (2) impingement syndrome status post arthroscopic surgery; and (3) spinal stenosis, cervical spine. The report also noted that the veteran's cervical injury would be related to his "original injury by description." There is no indication that the veteran's claims file or other medical records were reviewed pursuant to this examination. An occupational therapy report, dated in December 1996, noted that physical examination of the veteran revealed: Right shoulder flexion 0 to 110 degrees; left 0 to 110 degrees. Right shoulder extension 0 to 65 degrees; left 0 to 62 degrees. Right shoulder internal rotation L4; left sacropelvic. Right shoulder external rotation 0 to 64 degrees; left 0 to 49 degrees. Abduction 0 to 110 degrees, right; left 0 to 94 degrees. The report noted the veteran's complaints of pain during all movements, especially internal rotation. A treatment report, dated in February 1998, noted the veteran's complaints of neck and lower back pain which had worsened in the past week. An assessment of low back pain was given. A treatment report, dated in March 1998, noted the veteran's complaints of left knee pain. The report noted that the veteran "states injuring [left] knee playing ball 1 yr. ago." An X-ray examination of the spine, performed in March 1998, noted the following findings: The vertebral body height appears to be adequate. The vertebral disc space appears to be adequate. No fractures or dislocations seen. Small anterior osteophyte off the L4 vertebral body is incidentally noted. In May 1999, a VA examination of the spine was conducted. The report of this examination noted the veteran's narrative history of falling off of a truck while in the service in 1971. The veteran reported that he injured his right shoulder playing basketball while in the service. He also indicated that he has experienced intermittent muscle spasms and "pain in his neck for several years." The report also stated that: The patient does not "recall" an injury to his lower back. Eight to ten years ago, he developed pain in the lower back. Now, it hurts for him to get up and down from the sitting position. He has to be careful how he does things or will aggravate his low back pain. The patient had a left arthroscopic acromioplasty in 1996. Now, it hurts if he lays on his left shoulder and he has intermittent aching pain in it. Physical examination revealed, in part: RIGHT SHOULDER: The patient has no swelling, effusion, deformity, increased heat. He has the following range of active motion, limited by complaints of pain: Flexion = 90 degrees; Abduction = 90 degrees; Internal rotation = 90 degrees; External rotation = 90 degrees. He had no tenderness, weakness or evidence of atrophy. He was tender anterolaterally over the greater tuberosity. LEFT SHOULDER: The patient had no swelling, effusion, deformity or discoloration. He had the following range of active motion: Flexion = 110 degrees; Abduction = 110 degrees; Internal rotation = 30 degrees; External rotation = 90 degrees. He was tender over the greater tuberosity anterolaterally. He had no crepitation, atrophy, deformity or evidence of weakness. A normal range of motion for the shoulder is flexion 180 degrees, Abduction 180 degrees, Internal Rotation 90 degrees; External Rotation 90 degrees. X-ray examination of the left shoulder, performed in May 1999, revealed early changes of degenerative arthritis at the glenohumeral joint. The report also noted that the acromioclavicular joint appears unremarkable. X-ray examination of the right shoulder, performed in March 1999, revealed a small osteophyte on the inferior aspect of the lateral end of the clavicle. X-ray examination of the veteran's spine revealed an erect posture without pelvic obliquity or scoliosis, a reduced range of motion, and limited straight leg rasing due to hamstring tightness. From a neurological standpoint, the report noted: Deep tendon reflexes were active and equal in the biceps, triceps and patella tendons. I could elicit no reflex in the Achilles tendon in either ankle. I could detect no motor weakness or sensory deficits in the upper or lower extremities. There was no evidence of atrophy present. The report concluded with the following impressions: (1) history of dislocation, left shoulder with mild osteoarthritis; (2) minimal osteoarthritis, right acromioclavicular joint; (3) impingement syndrome, right shoulder; and (4) degenerative disk disease, C5-6, without neurologic deficit. The report also noted that "[b]y physical and xray examination, I can find no objective evidence of organic pathology." The VA examiner further commented that: The patient has no evidence of weakness in either shoulder. He has well developed, normal bulk of his muscles indicative of no atrophy. I could demonstrate no instability in either shoulder by abducting and internally rotation the shoulder 90 degrees and applying pressure on the posterior aspect of the head. No subluxation or dislocation could be measured. Fatigability is vague and subjective complaint which cannot be measured. Incoordination is a function of the central nervous system and not the shoulders. The patient is right handed. It is more likely than not, that the degenerative disk disease in the cervical spine developed after the patient's discharge from the service and is not related to his shoulder disorder. I do not believe that the shoulder disorder would aggravate the degenerative disk disease in his cervical spine. The patient's history suggests that he developed low back pain during the 80s, which was at least five years or more after his discharge from the military. I do not believe his low back pain is the result of his service connected bilateral shoulder disorders. I do not believe that his service connected shoulder disorders made his back pain worse. II. Analysis Review of the veteran's claims requires the Board to provide a written statement of the reasons or bases for its findings and conclusions on material issues of fact and law. 38 U.S.C.A. § 7104(d)(1) (West 1991). The statement must be adequate to enable a claimant to understand the precise basis for the Board's decision, as well as to facilitate review by the Court. See Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Masors v. Derwinski, 2 Vet. App. 181, 188 (1992). To comply with this requirement, the Board must analyze the credibility and probative value of the evidence, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the veteran. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board may not base a decision on its own unsubstantiated medical conclusions but, rather, may reach a medical conclusion only on the basis of independent medical evidence in the record or adequate quotation from recognized medical treatises. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. See also Alemany v. Brown, 9 Vet. App. 518, 519 (1996). A. Claims for Increased Disability Evaluations The veteran's claims for increased ratings are "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, he has presented a claim which is plausible. His assertion that his service-connected bilateral shoulder disorders have increased in severity is plausible. See Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992) (where a veteran asserted that his condition had worsened since the last time his claim for an increased disability evaluation for a service-connected disorder had been considered by VA, he established a well-grounded claim for an increased rating). All relevant facts have been properly developed and no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Service-connected disabilities are rated in accordance with a schedule of ratings, which are based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). The disability ratings evaluate the ability of the body to function as a whole under the ordinary conditions of daily life, including employment. Evaluations are based on the amount of functional impairment; that is, the lack of usefulness of the rated part or system in self- support of the individual. 38 C.F.R. § 4.10 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (1999). In DeLuca v. Brown, 8 Vet. App. 202 (1995), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. §§ 4.40, 4.45 and 4.59 were not subsumed into the diagnostic codes under which a veteran's disabilities are rated. Id. Therefore, the Board has to consider the "functional loss" of a musculoskeletal disability under 38 C.F.R. § 4.40, separate from any consideration of the veteran's disability under the diagnostic codes. DeLuca, 8 Vet. App. at 206. Functional loss may occur as a result of weakness or pain on motion of the affected body part. 38 C.F.R. § 4.40 (1999). VA regulation 38 C.F.R. § 4.40 describes functional loss and indicates that: Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40 (1999). The factors involved in evaluating, and rating, disabilities of the joints include: weakness; fatigability; incoordination; restricted or excess movement of the joint; or, pain on movement. 38 C.F.R. § 4.45 (1999). Specifically, § 4.45 states that: As regards the joints the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.). (b) More movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.). (c) Weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.). (d) Excess fatigability. (e) Incoordination, impaired ability to execute skilled movements smoothly. (f) Pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. For the purpose of rating disability from arthritis, the shoulder, elbow, wrist, hip, knee, and ankle are considered major joints; multiple involvement of the interphalangeal, metacarpal and carpal joints of the upper extremities, the interphalangeal, metatarsal and tarsal joints of the lower extremities, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae, are considered groups of minor joints, ratable on a parity with major joints. The lumbosacral articulation and both sacroiliac joints are considered to be a group of minor joints, ratable on disturbance of lumbar spine functions. 38 C.F.R. § 4.45 (1999). VA regulations also specifically address painful motion and state: With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or maligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight bearing and non-weight bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (1999). i. Traumatic Arthritis, Right (Major) Shoulder with History of Dislocation and Impingement Syndrome The veteran's service-connected traumatic arthritis, right (major) shoulder with history of dislocation and impingement syndrome, is currently evaluated as 20 percent disabling under Diagnostic Codes 5010 and 5203. He alleges that the symptoms resulting from this condition warrant assignment of an increased disability evaluation. Pursuant to Diagnostic Code 5010, arthritis due to trauma, substantiated by X-ray findings, shall be rated as degenerative arthritis pursuant to Diagnostic Code 5003. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, degenerative arthritis is evaluated at 10 percent where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and at 20 percent where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Id. Diagnostic Code 5003 does not provide disability ratings in excess of 20 percent. Pursuant to Diagnostic Code 5203, a 20 percent disability is warranted for the dislocation or nonunion with loose movement of the clavicle or scapula. A higher disability rating is not available under this code section. 38 C.F.R. § 4.71a, Diagnostic Code 5203 (1999). Under Diagnostic Code 5201, limitation of motion of the major arm at the shoulder level is assigned a 20 percent disability rating. Limitation of motion of the major arm midway between the side and shoulder level is assigned a 30 percent disability rating. Limitation of motion of the major arm to 25 degrees from side warrants a 40 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The regulations define normal range of motion for the shoulder as forward flexion from zero to 180 degrees, abduction from zero to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. 38 C.F.R. § 4.71, Plate I (1999). With forward elevation (flexion) and abduction, range of motion for the arm is from the side of the body (zero degrees) to above the head (180 degrees) with the mid-point of 90 degrees where the arm is held straight out from the shoulder. Id. In this case, Diagnostic Code 5201, contemplating a limitation of motion of the arm, is the appropriate code to rate the veteran's service-connected right shoulder disorder. After reviewing the evidence, however, the Board is unable to find any clinical findings showing such limitation of motion to warrant a rating in excess of 20 percent under this diagnostic code. It appears from the medical record that the veteran is able to move his right (major) upper extremity up to shoulder level. Specifically, the veteran's most recent VA examination for joints, performed in May 1999, noted that his right shoulder exhibited a range of motion of forward flexion to 90 degrees; abduction to 90 degrees; internal rotation to 90 degrees; external rotation to 90 degrees. The report also indicated that there was no swelling, effusion, deformity or increased heat. It also indicated that there was no tenderness, weakness or evidence of atrophy. The report of the veteran's October 1996 VA examination for joints noted a range of motion of forward flexion to 160 degrees and abduction to 160 degrees, internal rotation to 90 degrees and external rotation to 90 degrees. After reviewing the clinical findings of record, the Board finds that no clinical findings to date support a limitation of motion of the right (major) shoulder to more than a 20 percent evaluation. Thus, under Diagnostic Codes 5010-5201, the veteran would not be entitled to a higher rating than the 20 percent currently in effect. In making its determination herein, the Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The evidence shows that the veteran's right shoulder complaints consist primarily of pain on use. Nevertheless, the report of his most recent VA examination, dated in May 1999, noted that "[t]he patient has no evidence of weakness in either shoulder. He has well developed, normal bulk of his muscles indicative of no atrophy." The VA examiner further commented that he "could demonstrate no instability in either shoulder by abducting and internally rotating the shoulder 90 degrees and applying pressure on the posterior aspect of the head." While the veteran certainly experiences some functional loss as a result of his right shoulder condition, as evidenced by the medical treatment reports indicating that he has difficulty with his job duties because of this disability, the rating schedule does not require a separate rating for pain. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Thus, the Board concludes that the currently assigned 20 percent disability rating adequately compensates the veteran for his service-connected right shoulder disability and for any increased functional loss he may experience with physical activities above the shoulder level. See Sanchez-Benitez v. West, No. 97-1948 (U.S. Vet. App. Dec. 29, 1999); The veteran's contentions on appeal have been accorded careful and compassionate consideration; however, the Board finds that the recent medical findings discussed above are more probative of the current level of disability. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Accordingly, the Board concludes the preponderance of the evidence in this case is against the criteria for the next higher schedular evaluation for a right shoulder disorder. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5010-5201 (1999). The Board notes that the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (en banc). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this regard, the veteran's right shoulder disorder was originally rated under Diagnostic Code 5203, relating to impairment of the clavicle. Diagnostic Code 5203, with a maximum rating of 20 percent, provides that impairment of the clavicle can be alternatively rated on impairment of function of the contiguous joint. 38 C.F.R. § 4.71a, Diagnostic Code 5203 (1999). Thus, in absence of any current medical evidence of dislocation, malunion or nonunion of the clavicle, the Board concludes that the veteran's service-connected traumatic arthritis, right (major) shoulder with history of dislocation and impingement syndrome, is most appropriately rated under Diagnostic Codes 5010, relating to traumatic arthritis, and 5201, relating to limitation of motion of the arm. In Esteban v. Brown, 6 Vet. App. 259, 262 (1994), the Court held that evaluations for distinct disabilities resulting from the same injury could be combined so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. As the evaluation of the same manifestation under different diagnoses is precluded in the rating schedule, a separate rating under Diagnostic Code 5203 is not permitted. As noted above, Diagnostic Code 5203 allows for an alternative rating based on the impairment of function of contiguous joint. In addition, there is no showing of any additional disability, i.e. dislocation, nonunion or malunion, separate from the veteran's limitation of motion of the right shoulder. See 38 C.F.R. § 4.14 (1999); VAOPGCPREC 23-97 (O.G.C. Prec. 23-97) and VAOPGCPREC 9-98 (O.G.C. Prec. 9-98). ii. Traumatic arthritis, left (minor) shoulder, status post acromioplasty with history of dislocation and impingement syndrome The veteran's service-connected traumatic arthritis, left (minor) shoulder, status post acromioplasty with history of dislocation and impingement syndrome, is currently evaluated as 20 percent disabling under 38 C.F.R.§ 4.71(a) Diagnostic Codes 5010 and 5203. According to Diagnostic Code 5010, traumatic arthritis is to be evaluated as degenerative arthritis under Diagnostic Code 5003. Degenerative arthritis is to be evaluated based on the limitation of motion of the joint, but if the disorder is noncompensable under the applicable diagnostic code due to insufficient limitation in the range of motion, the disorder is evaluated at 10 percent. Thus, since traumatic arthritis is evaluated under diagnostic codes which provide for ratings based on limitation of motion, the evaluation assigned for such disability must take into account the decision of the United States Court of Appeals for Veterans Claims (Court) in DeLuca, 8 Vet. App. 202, in the evaluation of these disabilities. The veteran's left shoulder disability is currently evaluated under Diagnostic Code 5203. A 20 percent disability evaluation under Diagnostic Code 5203 contemplates dislocation or nonunion of the clavicle or scapula, and is the maximum assignable under that code section. 38 C.F.R. Part 4, Diagnostic Code 5203 (1999). A higher evaluation is available under Code 5201 where evidence demonstrates limitation of minor arm motion to 25 degrees from the side. 38 C.F.R. Part 4, Diagnostic Code 5201 (1999). Additionally, higher evaluations are appropriate if the humerus demonstrates loss of head, nonunion, or fibrous union. 38 C.F.R. Part 4, Diagnostic Code 5202 (1999). After a thorough review of the veteran's claims file, the Board concludes that the veteran's traumatic arthritis, left (minor) shoulder, status post acromioplasty with history of dislocation and impingement syndrome, is most appropriately rated as 20 percent disabling. In reaching this decision, however, the Board concludes that the veteran's service- connected left shoulder disorder is most appropriately rated pursuant to Diagnostic Codes 5010 and 5201. There is no medical evidence of record showing a dislocation, nonunion or malunion of the veteran's clavicle or scapula for many years. The report of his most recent VA examination for joints, performed in May 1999, noted that the VA examiner could not demonstrate instability, with pressure, in either of the veteran's shoulders. Thus, the Board concludes that the veteran's left shoulder disorder is more appropriately rated under Diagnostic Codes 5010 and 5201. The currently assigned 20 percent evaluation requires either limitation of motion of the minor arm at the shoulder level or midway between the side and shoulder level. A 30 percent disability rating for the minor extremity is warranted where there is a limitation of motion of the arm to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (1999). The veteran's most recent VA examination for joints, conducted in May 1999, noted that his left (minor) arm exhibited a range of motion of forward flexion to 110 degrees; abduction to 110 degrees; internal rotation to 30 degrees; external rotation to 90 degrees. His previous VA examination for joints, performed in October 1996, noted a range of motion of forward flexion to 160 degrees; abduction to 160 degrees; internal rotation to 90 degrees; external rotation to 90 degrees. Thus, the medical evidence of record does not demonstrate that the veteran's left shoulder disability merits an evaluation in excess of 20 percent. The veteran is not entitled to a higher rating under Diagnostic Code 5201 since arm motion is not limited at 25 degrees from his side, and there is no impairment of the humerus which would allow a higher evaluation under Diagnostic Code 5202. 38 C.F.R. Part 4, Diagnostic Codes 5201, 5202 (1999). In making its determination herein, the Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca, 8 Vet. App. 202 (1995). The May 1999 VA examination report also noted that "[t]he patient has no evidence of weakness in either shoulder. He has well developed, normal bulk of his muscles indicative of no atrophy." Thus, the Board finds that the veteran's subjective complaints of shoulder ache and pain on motion of the left shoulder are adequately compensated by the current 20 percent disability evaluation assigned. Sanchez- Benitez, supra ; DeLuca, supra.; 38 C.F.R. §§ 4.40, 4.45, 4.59 (1999). The Board concludes that the preponderance of the evidence in this case is against the criteria for the next higher schedular evaluation for service-connected traumatic arthritis, left (minor) shoulder, status post acromioplasty with history of dislocation and impingement syndrome. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5201, 5202, 5203 (1999). B. Claims for Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 101(16), 1110, 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). Service connection may be established for a current disability in several ways, including on a "direct" basis, on the basis of "aggravation," and on a "secondary" basis. 38 U.S.C.A. §§ 101(16), 1110, 1153 (West 1991); 38 C.F.R. §§ 3.303, 3.304(a), (b), (c), 3.306(a), (b), 3.310(a) (1999). Direct service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(a), (b), (d) (1999). Establishing direct service connection for a disability which has not been clearly shown in service requires the existence of a current disability and a relationship or connection between that disability and a disease contracted or an injury sustained during service. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303(d) (1999); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). With regard to a claim for secondary service connection, a claimant must provide competent evidence that the secondary condition was caused by the service-connected condition. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). The law provides that "a person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." 38 U.S.C.A. § 5107(a) (West 1991). 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 [section 5107(a)]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Generally, for a service-connection claim to be well grounded, a claimant must submit evidence of each of the following: (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the asserted inservice injury or disease and the current disability. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Elkins v. West, 12 Vet. App. 209, 213 (1999) (en banc) (citing Caluza, supra, and Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997) (expressly adopting definition of well- grounded claim set forth in Caluza, supra), cert. denied sub nom. Epps v. West, 524 U.S. 940, 118 S. Ct. 2348, 141 L. Ed. 2d 718 (1998) (mem.)). Alternatively, either or both of the second and third Caluza elements can be satisfied, under 38 C.F.R. § 3.303(b) (1999), by the submission of (a) evidence that a condition was "noted" during service or during an applicable presumption period; (b) evidence showing post service continuity of symptomatology; and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post service symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). The credibility of the evidence presented in support of a claim is generally presumed when determining whether it is well grounded. See Elkins, 12 Vet. App. at 219 (citing Robinette v. Brown, 8 Vet. App. 69, 75-76 (1995)). However, the presumption of credibility does not apply where a fact asserted is beyond a person's competency or where the evidence is inherently false. See id. For purposes of determining whether a well-grounded claim for secondary service connection has been established, it must first be determined whether the veteran's contentions are competent to establish that the service-connected condition caused the claimed injury or disease resulting in disability, and second, it must be determined whether medical evidence has been submitted to support the contention that the service-connected condition caused the disability for which secondary service connection is being sought. See Jones v. West, 12 Vet. App. 383 (1999) (quoting Reiber v. Brown, 7 Vet. App. 513 (1995)). The evidence submitted in support of a claim must be accepted as true for the purposes of determining whether the claim is well grounded except when the evidentiary assertion is "inherently incredible" or when the fact asserted is beyond the competence of the person making the assertion. See King v. Brown, 5 Vet. App. 19, 21 (1993). i. Lower Back and Cervical Spine Disorder As alluded to above, the Board previously remanded this case in March 1999 for additional development, to include scheduling the veteran for VA examination to assess the nature and etiology of the claimed disorders involving the veteran's cervical spine and lower back, relative to his active duty service and his service-connected bilateral shoulder disorders. An examination of the veteran was scheduled and conducted by VA in May 1999. After a thorough review of the veteran's claims file, the Board concludes that the veteran has not submitted evidence sufficient to render his claims of service connection for cervical and back disorders, on a direct basis and secondary to his service-connected disabilities, well grounded. Jones, 12 Vet. App. 383. The VA examiner conducting the May 1999 VA examination concluded that "[i]t is more likely than not, that the degenerative disk disease in the cervical spine developed after the patient's discharge from the service and is not related to his shoulder disorder. I do not believe that the shoulder disorder would aggravate the degenerative disk disease in his cervical spine. The patient's history suggests that he developed low back pain during the 80s, which was at least five years or more after his discharge from the military. I do not believe his low back pain is the result of his service connected bilateral shoulder disorders. I do not believe that his service connected shoulder disorders made his back pain worse." A follow-up treatment report, dated in October 1996, noted that the veteran was "seen for low back pain that had begun in the 1980's but increased in the past several months along with increasing cervical spine pain." After reviewing the findings on MRI and X-ray examinations, the VA physician treating the veteran concluded that "[t]he shoulder problem is unrelated to the lumbar [and] cervical spine problem." The veteran's contentions herein are not sufficient to well ground his claims under the standard set forth in Jones, supra, because the questions to be resolved concern the etiology of medical conditions. Therefore, competent medical evidence must show that the veteran's service-connected disabilities caused or aggravated one of these disorders. In the alternative, competent medical evidence must show that the veteran's current cervical spine or back disorders were incurred or aggravated during his active duty service. A mere allegation of a direct cause-and-effect relationship will not suffice to well ground this claim. The veteran's December 1996 VA examination for joints detailed as history the veteran's narrative history of falling out of a truck during service, thereby dislocating both of his shoulders and injuring his cervical spine. The VA examiner conducting the examination noted that it was his opinion that the veteran's cervical spine disorder was related to this "original injury by description." There is no indication, however, that this opinion was based upon anything other than the veteran's own narrative history of an inservice injury. Evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by that examiner, does not constitute "competent medical evidence." LeShore v. Brown, 8 Vet. App. 406 (1995); see also Robinette v. Brown, 8 Vet. App. 69 (1995) ("Bare transcription of a lay history is not transformed into 'competent medical evidence' merely because the transcriber happens to be a medical professional.") Specifically, the December 1996 opinion does not reference or discuss the lack of any complaints regarding a cervical spine disorder during service or in the years thereafter. The veteran's discharge examination, dated in April 1973, noted that his back and neck were normal. VA orthopedic examinations, conducted in September 1975 and June 1991, were also silent as to any complaints concerning a cervical or low back disorder. The earliest post service medical records relating to treatment of a cervical spine or back disorder occurred in 1996, 23 years after the veteran's discharge from active duty service. Based upon the failure of this opinion to take into account the complete facts of record, i.e., the lack of a spinal injury during service, the Board concludes that this opinion is not evidence linking the veteran's current cervical spine disorder to an inservice injury. Swann v. Brown, 5 Vet. App. 229, 233 (1993). Accordingly, under the standard set forth by the Court in Jones, supra, the veteran's claims are not well grounded. Moreover, the Board notes that under the Court's holding in Allen v. Brown, 7 Vet. App. 439 (1995) (aggravation of non service-connected disability by service-connected disability as a basis for an entitlement under 38 C.F.R. § 3.310(a)), there is no medical evidence which supports a theory that a service-connected disability aggravates one or more of the disorders claimed. See Beausoleil v. Brown, 8 Vet. App. 459, 464 (1996) (with respect to medical nexus for well groundedness, the claimant must supply objective medical evidence to support claim). Lastly, there is no competent evidence of record relating the veteran's current cervical and back disorders to his active duty service. The Board has considered the veteran's contentions and hearing testimony; however, this evidence alone cannot meet the burden imposed by 38 U.S.C.A. § 5107(a) with respect to the existence of a disability and a relationship between the disability and a service-connected disorder. Espiritu, 2 Vet. App. 492 (1992). As indicated above, his lay assertions will not support a finding on medical questions requiring special expertise or knowledge, such as diagnosis or causation of a disease. Id. at 494-95. On the basis of the above findings, the Board can identify no basis in the record that would make these claims plausible or possible. 38 U.S.C.A. § 5107(a); see also Grottveit, 5 Vet. App. at 92, Tirpak v. Derwinski, 2 Vet. App. 609, 610-11 (1992); and Murphy, 1 Vet. App. at 81. Where the veteran has not met this burden, the VA has no further duty to assist him in developing facts pertinent to a claim, including no duty to provide further medical examination or solicitation of medical opinion evidence. 38 U.S.C.A. § 5107(a); Rabideau, 2 Vet. App. at 144 (where the claim is not well grounded, VA is under no duty to provide the veteran with an examination); see also Morton v. West, 12 Vet. App. 477 (1999) (if a well-grounded claim has not been submitted, there is no duty on the part of VA to assist in the claim's full development). VA is obligated under 38 U.S.C.A. § 5103(a) to advise a claimant of the kind of evidence needed to well ground a claim for service connection. Robinette, 8 Vet. App. 69 (1995). However, here unlike the situation in Robinette, the veteran has not put the VA on notice of the existence of any specific, particular piece of evidence that, if submitted, could make his claims considered herein plausible or well grounded. See also Epps v. Brown, 9 Vet. App. 341 (1996). The Board concludes that VA did not fail to meet its obligations under 38 U.S.C.A. § 5103(a) (West 1991). Accordingly, the Board must deny the veteran's claims seeking entitlement to service connection for cervical spine disorder and a back disorder, on a direct basis and secondary to bilateral service-connected shoulder disabilities, as not well grounded. See Edenfield v. Brown, 8 Vet. App. 384 (1996) (en banc) (disallowance of a claim as not well grounded amounts to a disallowance of the claim on the merits based on insufficiency of evidence). (CONTINUED ON NEXT PAGE) ORDER Entitlement to an increased disability evaluation in excess of 20 percent for service-connected traumatic arthritis, right (major) shoulder with history of dislocation and impingement syndrome, is denied. Entitlement to an increased disability evaluation in excess of 20 percent for service-connected traumatic arthritis, left (minor) shoulder, status post acromioplasty with history of dislocation and impingement syndrome, currently rated as 20 percent disabling. Because it is not well grounded, the veteran's claim for service connection for a back disorder, on a direct basis and secondary to the veteran's service-connected bilateral shoulder disorders, is denied. Because it is not well grounded, the veteran's claim for service connection for a cervical spine disorder, on a direct basis and secondary to the veteran's service-connected bilateral shoulder disorders, is denied. BETTINA S. CALLAWAY Member, Board of Veterans' Appeals