Citation Nr: 0001993 Decision Date: 01/27/00 Archive Date: 02/02/00 DOCKET NO. 93-12 578 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for epigastric distress (claimed as stomach condition). 2. Entitlement to service connection for a heart condition. 3. Entitlement to service connection for fibrocystic breast disease, bilateral (claimed as breast condition). 4. Whether the decision to sever service connection for vaginitis effective April 30, 1999, was correct. 5. Entitlement to a rating higher than 10 percent for vaginitis. 6. Entitlement to a rating higher than 10 percent for left knee chondromalacia. 7. Entitlement to a rating higher than 10 percent for right knee chondromalacia. 8. Entitlement to a compensable rating for right Achilles tendonitis,. 9. Entitlement to a compensable rating for low back pain. 10. Entitlement to a compensable rating for a panic disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Gallagher, Counsel INTRODUCTION The veteran served on active duty from October 1987 to January 1990 with additional service in the United States Army Reserve. This matter comes before the Board of Veterans' Appeals (Board) from September 1991, May 1996, August 1997, and February 1999 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In the September 1991 rating decision, the RO denied service connection for some disorders and granted service connection for others. (To avoid confusion in tracing the history of the many claims involved in this case, the Board will use the same number to designate each issue that is used on the cover page of this decision.) The veteran appealed the following aspects of the September 1991 rating decision to the Board: the denial of service connection for a stomach disorder (#1); the denial of service connection for a back (service connection granted, May 1996 rating decision) and neck (service connection granted, February 1999 rating decision) disorder; the denial of service connection for a nervous condition (service connection granted, May 1996 rating decision); denial of service connection for a heart condition (#2); the denial of service connection for a breast condition (#3); the initial assignment of a 10 percent rating for service-connected vaginitis (#5); the initial assignment of a 10 percent rating for service-connected chondromalacia, both knees (#6 & #7); the initial assignment of a noncompensable rating for service-connected Achilles tendonitis, right (#8); and the initial assignment of a noncompensable rating for service-connected allergic rhinitis (appeal withdrawn by the veteran, October 1997). The Board remanded the case for further development of the evidence in March 1995. In a May 1996 rating decision, the RO continued the denials of service connection for epigastric distress (claimed as a stomach condition) (#1); a heart condition with systolic murmur (#2); and fibrocystic breast disease, bilateral (#3); and continued the rating of 10 percent for chondromalacia, both knees (#6 & #7); and noncompensable ratings for right Achilles tendonitis (#8) and allergic rhinitis (appeal withdrawn, October 1997). In the May 1996 rating decision, the RO also proposed to sever service connection for vaginitis and granted service connection for left sacroiliac strain with low back pain and for panic disorder, assigning noncompensable initial ratings for these two disorders. In June 1996, the RO received copies of medical reports with portions highlighted in yellow. Interspersed in these reports were statements from the veteran including statements expressing disagreement with the proposal to sever service connection for vaginitis (#4); with the initial noncompensable ratings assigned for the low back pain (#9) and panic disorder (#10); and with the RO's not having addressed the claim for service connection for a neck disorder (service connection granted, February 1999 rating decision). Although a February 1999 supplemental statement of the case provides notice to the veteran that the allowance of service connection for the low back pain and panic disorder represents a full resolution of the appeal of the service connection issues -- which is true -- no statement of the case was ever issued following the June 1996 notices of disagreement with the noncompensable ratings assigned for the low back pain and panic disorder. Cf. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed.Cir. 1997) (an appeal initiated by a notice of disagreement as to an RO's "rejection of the logically up-stream element of service-connectedness . . . could not concern the logically down-stream element of compensation level."). Accordingly, the Board will address this situation in the Remand which follows this decision (#9 & #10). Manlicon v. West, 12 Vet. App. 238, 240-41 (1999) (holding that, where notice of disagreement is filed with claim and no statement of the case has been issued, Board should remand, not refer, that issue to the RO to issue statement of the case). The Board has decided to restore service connection for vaginitis, severance of which was proposed in a May 1996 rating decision and accomplished in an August 1997 rating decision (#4). Before service connection for vaginitis was severed, the veteran had perfected an appeal to the Board of the initial assignment of a 10 percent rating for vaginitis. After severing service connection, the RO, in a February 1999 supplemental statement of the case, considered the issue on appeal as whether an initial disability rating higher than 10 percent was warranted for vaginitis during the period that service connection and the 10 percent rating had been in effect for the disorder. Given the Board's restoration of service connection for vaginitis, the Board has recharacterized the issue as one for entitlement to a rating higher than 10 percent for vaginitis (#5), and this issue is addressed in the Remand. A hearing was held before a VA hearing officer in October 1997, at which time the veteran submitted a statement withdrawing her appeal of the initial noncompensable rating assigned for allergic rhinitis. Therefore, this issue is no longer on appeal. 38 C.F.R. § 20.204 (1999). Concerning the veteran's disagreement with the RO's not having addressed the claim for service connection for a neck disorder, the RO did address this issue in the February 1999 rating decision by granting service connection for cervical spine degenerative disc disease and assigning a 20 percent disability rating for that disorder. This allowance of service connection represents a full grant of the benefits sought on appeal to the Board, and therefore, the issue is no longer before the Board. Grantham, 114 F.3d at 1158-59. In addition to its actions concerning the vaginitis claim and its grant of service connection for cervical spine degenerative disc disease, the RO, in the February 1999 rating decision, also continued the denial of service connection for epigastric distress (claimed as stomach condition) (#1); for a heart condition (#2); and for fibrocystic breast disease, bilateral (claimed as breast condition) (#3); continued the noncompensable rating assigned for right Achilles tendonitis (#8); and granted separate initial ratings of 10 percent each for chondromalacia of the left (#6) and right (#7) knees. The Board has decided that the claim for service connection for fibrocystic breast disease, bilateral (claimed as breast condition), is a well grounded claim. However, because an August 1995 VA examination report pertaining to fibrocystic breast disease inadequately met the requirements specified in the Board's March 1995 remand order regarding the claim for service connection for fibrocystic breast disease, bilateral (claimed as breast condition), this claim must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. No medical evidence has been presented to render plausible a claim that a stomach disorder exists currently that accounts for the symptoms described by the veteran or that symptoms of epigastric distress, pain, or "twisting" in the stomach, for which the veteran claims service connection, constitute, in themselves, a current disability for the purposes of establishing a well grounded claim for service connection for epigastric pain (claimed as a stomach condition). 2. No medical evidence has been presented or secured to render plausible a claim that a current heart condition, if any, had its onset in service or is related to a disease or injury incurred in service. 3. The veteran had fibroadenoma diagnosed in 1970, prior to active duty, and had cysts surgically removed from her breasts at that time. 4. The veteran currently has fibrocystic breast disease. 5. Findings on a mammogram in service in 1989 may represent an increase in severity of a preexisting breast disease or the onset of a breast disorder that is separate and distinct from the fibroadenoma diagnosed prior to service. 6. The evidence of record does not demonstrate clearly that vaginitis was not aggravated in active service. 7. Chondromalacia of the knees has been manifested by complaints of pain with normal range of motion during the period contemporaneous with the initial rating of the disorder, and those manifestations have continued up to present. 8. Right Achilles tendonitis has been manifested by tenderness to palpation of the right Achilles tendon insertion, a range of nonpainful dorsiflexion of the right ankle two degrees less than the range on the left; mild tendonitis, with no more than a slight degree of disability and by complaints of pain only, with findings of examiners that the tendonitis had "healed" or "resolved." CONCLUSIONS OF LAW 1. The claim for service connection for epigastric pain (claimed as a stomach condition) is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim for service connection for a heart condition is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The claim for service connection for fibrocystic breast disease, bilateral (claimed as breast condition) is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The September 1991 rating decision granting service connection for vaginitis was not based on clear and unmistakable error, and restoration of service connection for vaginitis is warranted. 38 C.F.R. § 3.105(d) (1999) 5. A rating higher than 10 percent for chondromalacia of the left knee is not warranted. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5099-5024, 5260, 5261 (1999). 6. A rating higher than 10 percent for chondromalacia of the right knee is not warranted. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5099-5024, 5260, 5261 (1999). 7. A compensable rating for right Achilles tendonitis is not warranted. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.7, 4.56, 4.73, Diagnostic Codes 5399-5310 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Legal Requirements For Establishing Service Connection And For Establishing A Well Grounded Claim For Service Connection For A Disability. In general, establishing service connection for a disability on a direct basis requires the existence of a current disability and a relationship or connection between that disability and a disease or injury incurred in service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Service connection for a disability may also be established based on aggravation of disease or injury which preexisted service when there is an increase in disability during service unless the increase is due to the natural progress of the disease. 38 C.F.R. § 3.306(a) (1999). Establishing service connection for a disability based on aggravation requires (1) evidence sufficient to show that a disease or injury preexisted service; (2) evidence showing an increase in disability during service sufficient to raise a presumption of aggravation of the disability; and (3) a lack of clear and unmistakable evidence to rebut the presumption of aggravation which may include evidence showing that the increase in severity was due to the natural progress of the disability. 38 C.F.R. § 3.306(b) (1999). Concerning Item (1), a disorder may be shown to have preexisted service if it is noted at entrance into service or where clear and unmistakable evidence rebuts a legal presumption of sound condition at entrance for disorders not noted at entrance. History provided by the veteran of the preservice existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1) (1999); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). To establish a well grounded claim for service connection, a claimant has the burden to submit competent evidence to support each element of the claim, e.g., for direct service connection, the existence of a current disability; an injury sustained or disease contracted in service; and a link or nexus between the two. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Alternatively, the third Caluza element can be satisfied under 38 CFR 3.303(b) (1999) by evidence of continuity of symptomatology and medical or, in certain circumstances, lay evidence of a nexus between the present disability and the symptomatology. See Savage, 10 Vet. App. at 495. Evidence submitted in support of a claim "must . . . be accepted as true for the purpose 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." King v. Brown, 5 Vet. App. 19, 21 (1993). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110, 1131 (West 1991); see Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that Secretary's and Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Caluza v. Brown, 7 Vet. App. 498, 505 (1995); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v Derwinski, 2 Vet. App. 141, 143 (1992). The veteran has the burden to bring evidence to render plausible the existence of the disability for which she is claiming service connection in order to establish a well grounded claim. Until she does, the VA does not have the duty to assist her in developing facts pertinent to her claim, including assisting her by affording her a medical examination at VA expense. 38 U.S.C.A. § 5107(a) (West 1991); see Grivois v. Brown, 6 Vet. App. 136, 139-40 (1994) (noting that "implausible claims should not consume the limited resources of the VA and force into even greater backlog and delay those claims which . . . require adjudication."); see also Morton v. West, 12 Vet. App. 477, 485 (1999) (holding that the Secretary cannot, by regulation, Manual, and/or Compensation and Pension policy eliminate the condition precedent, i.e., the requirement that a claimant submit a well grounded claim, placed by Congress upon the inception of the Secretary's duty to assist). Service Connection For Epigastric Distress (Claimed As Stomach Condition). Background. Service medical records reflect that in July 1989, when being seen in a service department Mental Health Clinic after a death in her family, the veteran reported that she had had periodic anxiety symptoms to include "nervous stomach". The examiner diagnosed psychological factors affecting physical condition. There are no other complaints or findings relevant to a stomach condition in the service medical records. On July 1991 VA examination the history provided by the veteran included that in 1988 she had developed a "nervous twitching and quivering in the stomach." She stated that this had happened when she had some type of harassment during service. She reported that she was placed on nerve pills which improved the stomach condition. She stated that her stomach condition had improved since that time and she had less trouble with it currently. She was still taking nerve medication and sleeping medication which she felt improved the general state of her stomach. She was okay as long as she was not upset, which occurred about once a week. Examination of the abdomen revealed no localized pain, no organomegaly, no masses present, no tenderness. The doctor diagnosed "nervous stomach", helped by nerve medication, stabilized at present. A May 1992 VA Form 10-0043a, Medical Record Service Treatment Plan --Ambulatory Care Interdisciplinary Progress Note, showed that the veteran was seen with requests to have an abdominoplasty. An abdominoplasty is an operation performed on the abdominal wall for esthetic purposes. Stedman's Medical Dictionary 2 (26th ed. 1995). In March 1995, the Board remanded all of the claims for VA to assist in development of the evidence without determining whether the claims were well grounded as is now required. Morton, 12 Vet. App. at 485. Concerning service connection for epigastric distress (claimed as stomach condition), the Board ordered the RO to schedule the veteran for a VA examination to determine the presence, nature, and etiology of her claimed stomach disorder. The Board stated that the examiner should specifically comment as to whether the veteran currently exhibits a chronic stomach disorder. On August 1995 VA examination, the veteran gave a history of having begun to have epigastric discomfort and bloating in 1989 with a sharp pain in the upper portion of her epigastric area. She reported that she had been taking Motrin three times a day for her back and that she was told that this medication was increasing her epigastric discomfort. She reported that she continued to have this discomfort which occurred and lasted for approximately 24 hours in episodes that last both day and night. She stated that the episodes occurred about twice a month. She had no radiation of pain from the epigastric area. It did not radiate under the sternum or to the right or left upper quadrant or to the back. She took Mylanta with relatively good results. She stopped taking Motrin in 1991, and had an upper gastrointestinal (GI) series at a VA hospital in 1992, but never got the report. She reported that she was worried about the epigastric pain in her stomach because it caused her to lose time from work. Her discomfort was not progressive, but recurred one day every two weeks. The examiner noted that an upper (GI) series would be repeated. Examination of the abdomen revealed no masses, tenderness, or organomegaly. No abnormalities in the abdomen could be palpated. The diagnosis consisted of the history provided by veteran and the plan to obtain the upper GI series. An August 1995 VA upper GI series report indicates that a series was performed using barium swallow. Under "Impression", the radiologist only wrote, "See concurrent report case #15879" but a report by that number is not in the claims file and no other report pertaining to an upper GI series is in the claims file. At a hearing before a VA hearing officer in October 1997, the veteran testified that she was treated for a stomach condition in service. She stated that she began having a nervous stomach from harassment and that it was aggravated by taking Motrin for orthopedic problems. She did not recall any specific diagnosis in service except "nervous stomach." She stated she was not given a separation examination because the service department was unable to catch up with her. She stated that she had some tests done at a VA hospital as part of her VA examination but that she did not think the testing was accurate because she kept throwing up the material that she was required to swallow for the test. She stated the only type of medication she was taking currently for the stomach condition was over-the-counter antacids. She testified that she felt service connection was warranted for a stomach condition because she began having problems with her stomach in service and medication she took in service made the condition worse. She stated that she currently experienced epigastric distress three or four times a month. She had no nausea, vomiting, or burning. Her pain felt like she had had an operation, and "it just feels like somebody is twisting." She felt service connection should be granted because the condition interferes with her work and she has to take days off. Analysis. In claiming service connection for epigastric distress (claimed as a stomach condition), the veteran is claiming service connection for symptoms rather than for an underlying disability from which the symptoms derive. With regard to the element of a claim for service connection requiring the existence of a current disability, the Board notes that a veteran's statements as to subjective symptomatology alone, such as pain or "twisting" in the stomach, without medical evidence of an underlying impairment capable of causing the symptom alleged, generally cannot constitute plausible evidence of the existence of a current disability for VA service connection purposes. Sanchez-Benitez v. West, No. 97-1948 (U.S. Vet. App. Dec. 29, 1999). For example, where medical science has been unable to determine with certainty an underlying cause of certain symptoms, even when alleged in common by numerous veterans who constitute a specific population of veterans rather than just by one veteran, special legislation has been required to enable VA to assist that population of veterans. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); see also Hayes v. Brown, 9 Vet. App. 67, 72 (1996) (holding that, although appellant as a lay person can certainly provide an account of symptoms he experiences, the appellant is not competent to provide a medical diagnosis). No medical evidence has been presented or secured in this case to render plausible a claim that a stomach disorder exists currently that accounts for the symptoms described by the veteran or that symptoms of epigastric distress, pain, or "twisting" in the stomach, for which the veteran claims service connection, constitute, in themselves, a current disability for the purposes of establishing a well grounded claim for service connection for epigastric pain (claimed as a stomach condition). Accordingly, the claim for service connection for epigastric pain (claimed as a stomach condition) is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). In the March 1995 remand, the Board ordered a VA examination to determine the presence, nature, and etiology of the claimed stomach disorder. The diagnosis by the August 1995 VA examiner consisted merely of a recitation of the symptoms described by the veteran and the plan for an upper GI series, which apparently was conducted, but a report of which was not placed in the claims file. In Stegall v. West, 11 Vet. App. 268 (1998), the United States Court of Appeals for Veterans Claims (Court) held that, where the remand orders of the Board or the Court are not complied with, the Board errs as a matter of law when it fails to ensure compliance. One issue here is whether Stegall requires the Board to remand a claim which is not well grounded for compliance with a prior order for development of the evidence by the Board or whether such a second remand would run afoul of the Court's holding in Morton that VA cannot eliminate the condition precedent, i.e., the requirement that a claimant submit a well grounded claim, placed by Congress upon the inception of the Secretary's duty to assist. In Roberts v. West, No 97-1993, slip op. at 4-5 (U.S. Vet. App. Nov. 19, 1999), the Court distinguished Stegall, which concerned a well grounded claim for an increased rating for a service-connected condition from that appellant's claim for secondary service connection for arthritis which was not a well grounded claim and held that, because the claim for service connection was not well grounded, "additional action by the Board to enforce its remand order was not required under Stegall." Roberts, No. 97-1993, slip op. at 5. Similarly in this case, because the claim for service connection for a stomach disorder is not well grounded, the Board concludes that remand is not necessary. Cf. Brewer v West, 11 Vet. App. 228, 235-36 (1998) (holding that, where claims for service connection for back, knee, and left hip disorders were not well grounded and x-rays recommended by a physician were not performed, the Board was not required to remand the claims so that the x-rays could be accomplished under section 5107(a) because the Board had no duty to assist the claimant in developing the claim or to remand under section 5103(a) because there was no indication that the results of such x-rays would render the claim well grounded). Service Connection For A Heart Condition. Background. There are no complaints or findings relevant to a heart condition noted in the service medical records. On July 1991 VA Compensation and Pension (C&P) examination, the veteran's history included getting a fluttering in her heart and getting short of breath, lasting three or four seconds. She stated that this feeling happened three to four days out of the week and went away as abruptly as it came on. She had been evaluated before for this and was told it was nothing. On cardiovascular examination, the heart had a regular rate and rhythm with a II/IV systolic ejection murmur and a mid-systolic click. The peripheral pulses were 2+. The veteran was not hypertensive, and there were no varicose veins noted. The lungs were clear to auscultation and percussion, and the shape of the chest was normal female. The examiner diagnosed probable mitral valve prolapse. (Mitral valve prolapse is "excessive retrograde movement of one or both mitral valve leaflets into the left atrium during left ventricular systole, often allowing mitral regurgitation . . . ." Stedman's Medical Dictionary 1436 (26th ed. 1995)). An accompanying chest x-ray report was normal, although the radiologist noted that the film was unusually light and poorly developed due to a processing failure. An accompanying electrocardiogram (ECG) was normal and showed normal sinus rhythm. In the March 1995 Remand, the Board ordered the RO to schedule the veteran for a VA examination to determine the presence, nature, and etiology of her claimed heart disorder. The Board stated that the examiner should specifically comment as to whether the veteran currently exhibits a chronic heart disorder. Moreover, the Board ordered that a VA cardiologist provide an opinion as to whether the mitral valve prolapse identified on VA examination in July 1991 was a congenital or developmental disability. A May 1995 Emergency Department History and Physical report from St. Joseph Hospital showed that the veteran was seen with a history of dry cough, fever, chills, headache, and generalized body aches which started two days earlier. On the report of physical examination, the examiner noted that the veteran's pulse was 114 and blood pressure 140/70. The examiner also noted, "Heart: S1, S2. The patient is tachycardic." (Tachycardia is "[r]apid beating of the heart, conventionally applied to rates over 100 per minute." Stedman's at 1758.) The diagnoses were headache resolved; bronchitis; and thrombocytopenia. (Thrombocytopenia is "[a] condition in which there is an abnormally small number of platelets in the circulating blood." Stedman's at 1808.) On August 1995 VA examination, the veteran's chief complaint was chest pain, dyspnea, and flutter about once a month. She reported that this problem started while she was on active duty. She stated that every time she was in a stressful situation, she would develop chest pain with the pain radiating to her arm. She stated that this did not happen any more and that the only thing she still experienced was a flutter associated with some chest pain and dyspnea. She did not have any problems on exertion. She was able to climb three flights of stairs before she developed shortness of breath that did not cause any chest pain. She denied any association between chest pain and exertion. The examiner noted that review of the veteran's medical records did not reveal any diagnostic work up or any diagnosis of heart problem. On cardiac examination, there was normal sinus rhythm with a heart rate of 76. Respiration was 12, with blood pressure of 120/80. There was a Grade I systolic murmur to the left of the cardiac border which radiated laterally towards the left chest wall, very soft, with no irregularity. No arrhythmia was detected. There was no peripheral edema. Peripheral pulses were good. Various diagnostic studies were ordered. An August 1995 VA ECG report showed normal sinus rhythm and normal ECG. An August 1995 echocardiogram showed normal results including that pertaining to mitral valve function which showed no stenosis and trivial regurgitation. An August 1995 VA chest x-ray showed no cardiac abnormalities. In a handwritten addendum to the August 1995 VA examination, the examiner, after reviewing all the test results, wrote, "Normal echocardiogram. Normal EKG. Normal [left ventricular function]. No evidence of organic heart disease. Believe murmur is functional." (Functional means "[r]elating to a function. . . . Not organic in origin; denoting a disorder with no known or detectable organic basis to explain the symptoms." Stedman's at 693.) At a hearing before a VA hearing officer in October 1997, the veteran testified that her current symptoms were occasional fluttering with shortness of breath and discomfort. She stated the current symptoms were not as bad or as frequent as those she experienced on active duty. She experienced them when she was "stressed". When asked if doctors diagnosed a heart murmur or any type of cardiac problem while she was on active duty she stated that she "didn't have one on active duty," and that doctors "didn't hear it" but that right after discharge a doctor told her she had a heart murmur. Analysis. No medical evidence has been presented or secured to render plausible a claim that a current heart condition, if any, had its onset in service or is related to a disease or injury incurred in service. In this regard, the Board notes that assuming, without deciding, that the finding of "probable mitral valve prolapse" on the July 1991 VA examination was evidence of a current heart condition, no medical evidence has been presented to render plausible a claim that such a heart condition had its onset in service or is the result of a disease or injury incurred in service. Therefore, a claim for service connection for a heart condition on a direct basis is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). If cardiovascular-renal disease including hypertension manifests itself to a compensable degree within one year from the date of separation from service, the law presumes that the disease had its onset or was incurred in service even though there is no evidence of such disease during the period of service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (1999). The Board remanded the claim for service connection for a heart condition for further development of the evidence pertaining to the finding of "probable mitral valve prolapse" on the July 1991 VA examination. Although a "probable mitral valve prolapse" was first identified 18 months after separation from service, the veteran filed her claim for service connection for a heart condition in December 1990 within a year following discharge. However, no medical evidence has been presented to render plausible a claim that a "probable mitral valve prolapse" is an early symptom of, cardiovascular-renal disease including hypertension. Moreover, no medical evidence has been presented or secured to render plausible a claim that the veteran currently has cardiovascular disease, arteriosclerosis, or any other heart condition. Accordingly, a claim for service connection for a heart condition based on the presumptive provision for cardiovascular disease in section 3.309 is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). In its March 1995 remand order, the Board ordered that a VA examination be conducted to determine the presence, nature, and etiology of a claimed heart disorder and for an opinion as to whether the mitral valve prolapse identified on the July 1991 VA examination was a congenital or developmental disability. The August 1995 examiner complied in part with the Board's remand order, determining that there was no evidence of organic heart disease, but did not address whether there was a mitral valve prolapse and, if so, whether it was a congenital or developmental disability. Concerning the latter, the Board notes that service connection may be granted for diseases (but not defects) of congenital, developmental or familial origin if the evidence as a whole shows that the manifestations of the disease in service constituted "aggravation" of the disease within the meaning of applicable VA regulations. VAOPGCPREC 82-90 (July 18, 1990); 38 C.F.R. §§ 3.303(c), 3.306 (1999). With regard to congenital or developmental defects, service connection may not be granted for a defect, although service connection may be granted for a disability which is shown by the evidence to have resulted from a defect which was subject to a superimposed disease or injury during service. VAOPGCPREC 82-90 (July 18, 1990). However, whether the veteran has a mitral valve prolapse or not and whether it is a congenital disability or not, no medical evidence has been presented or secured to render plausible a claim that it had its onset in service; is the result of a disease or injury incurred in service; is a manifestation of cardiovascular disease, or, if a congenital disease or defect, was aggravated in service or subjected to a superimposed injury in service resulting in disability. Therefore, no matter how it is viewed, the claim for service connection for a heart condition to include a mitral valve prolapse is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). As was the case with the claim for service connection for a stomach condition, the question arises as to whether the Court's holding in Stegall requires the Board to remand a claim which is not well grounded for compliance with a prior order for development of the evidence by the Board or whether such a second remand would run afoul of the Court's holding in Morton that VA cannot eliminate the condition precedent, i.e., the requirement that a claimant submit a well grounded claim, placed by Congress upon the inception of the Secretary's duty to assist. For the same reasons and bases which the Board has articulated above with regard to the stomach claim, the Board concludes that it is not required to remand this case again under Stegall. Specifically, because the claim for service connection for a heart disorder including a mitral valve prolapse is not well grounded, the Board concludes that remand is not necessary to conduct a VA examination in which an examiner clearly articulates whether a mitral valve prolapse is a congenital or developmental disability. Fibrocystic Breast Disease, Bilateral (Claimed As Breast Condition). Background. An October 1976 report of an examination conducted in connection with service in the Army Reserve reflected a history of cysts removed from the right and left breasts in 1970 with no complications. The examiner noted that the breast examination was essentially normal. A letter, dated in October 1976, from the private physician who performed the bilateral breast biopsy in November 1970 reflected that the pathological diagnosis was fibroadenoma, entirely benign on both breast masses. (Fibroadenoma is "[a] benign neoplasm derived from glandular epithelium in which there is a conspicuous stroma of proliferating fibroblasts and connective tissue elements; commonly occurs in breast tissue." Stedman's at 648.) Service medical records reflect that a breast examination in March 1989 was normal. On a July 1989 mammography, it was noted that caudiocranial and mediolateral views were obtained and that, in the lateral aspect on right caudiocranial view there was a very questionable three centimeter density of which there was a questionable border. This finding was not confirmed on oblique or additional exaggerated caudiocranial view. The radiologist noted, "Overall, it is felt that this is ductile tissue." In August 1989, the veteran was referred by the obstetrical/gynecological clinic to the surgical clinic for an assessment. The assessment was "no surgical breast disease at this time." On July 1991 VA examination, history provided by the veteran included that in 1989 a mammogram showed multiple cystic disease in the breast and that in high school she had cysts removed from the breasts. Examination of the breasts revealed multiple small tender areas thought to be due to multiple cysts in each breast bilaterally. The examiner noted that a good deal of pain was present in the breasts so that adequate examination was somewhat difficult. The diagnosis was multiple cystic disease of the breast, proved by mammogram last done in 1989. July 1991 VA bilateral mammography reflected evidence of some fibrocystic changes in both breasts. There was no definite evidence of abnormal calcification or engorgement of vessels in either breast. There were no spiculated nodular lesions. The visualized skin and nipples were within normal limits. However, there was some prominence of the subareolar ductal patterns seen, more prominent on the left side. Axillary lymph nodes were demonstrated bilaterally. The impression was fibrocystic changes in both breasts. On March 1995 remand, the Board ordered that an additional VA examination be conducted to determine the presence, nature, and etiology of the claimed fibrocystic disease of the breasts. The Board specifically ordered that an appropriate specialist review the service medical records and provide an opinion "whether the fibrocystic disease present at the time of the veteran's entrance underwent a clinically significant increase in severity during the veteran's period of active service." On August 1995 VA examination, the veteran provided a history of having had pain in both breasts in high school and of having had cysts of the breasts removed. She also reported having experienced pain in the breasts on active duty in 1987 when having to run. She stated that mammography in 1989 revealed fibrocystic disease of the breast. She reported that a mammogram after service, in 1991 showed increase in the fibrocystic disease of the breast. She stated that she continued to have some discomfort in her breast in 1992 through 1995. She reported that painful episodes occurred throughout the month, but were worse during menstruation. Examination of the breasts revealed multiple small cysts, 0.5 cm in size, in the upper outer quadrants of both breasts and in the lower halves of her breasts, tender to palpation and tender to her examination. Scars of the breasts were well- healed, with no keloid formation and no tenderness. Under "Final Diagnosis", the examiner repeated the history provided by the veteran. The examiner stated, "Increase in severity of the fibrocystic disease in the breast occurred, according to the [veteran], in relation to the running that she did." August 1995 VA bilateral mammography showed that the breasts remained markedly glandular and relatively symmetric bilaterally. No discrete mass, malignant appearing calcification or skin change was identified. It was noted that a small nodule can be missed in dense breasts. Overall appearance had not changed appreciably. The impression was most likely benign, markedly glandular breasts, unchanged. Ultrasound correlation was recommended if clinical concern persisted on palpable nodule. Otherwise, continuous self-examination and routine annual follow-up were recommended. At a hearing before a VA hearing officer in October 1997, the veteran testified that she had a cyst removed from each breast prior to active duty, in 1970, and did not have any problems during the intervening years, but then started having problems on active duty and "it had multiplied." A mammogram showed multi-fibrocystic breast disease, and that she did not have that before coming on active duty. She had no problems with her breasts except they would bother her if she ran or something like that. She contended that she should be granted service connection because her preexisting breast disorder was aggravated during active duty and because she "did not have a multitude of fibrocysts in my breasts" prior to active duty. Analysis. The medical questions in this case are whether fibroadenoma diagnosed in 1970, seventeen years prior to active service, is related to or the same disease or disorder as the fibrocystic breast disease diagnosed currently and, if so, whether the findings of dense ductile tissue on a mammogram conducted during active duty in 1989 constitute an increase in severity of the preexisting breast disease beyond its normal progress. The Board concludes that, because the mammogram findings in service in 1989 may represent an increase in severity of a preexisting breast disease or the onset of a breast disorder that is separate and distinct from the fibroadenoma diagnosed prior to service, the claim for service connection for a breast condition is well grounded, and was well grounded when the Board remanded it in March 1995. 38 U.S.C.A. § 5107(a) (West 1991). Concerning this determination, the Board notes that the claim is well grounded based on the mammogram findings in service without regard to the normal finding on a March 1989 breast examination and the August 1989 surgical clinic finding that there was no "surgical" breast disease present because the Board must consider only the evidence that is or may be favorable to the claim in deciding whether a claim is well grounded. See Arms v. West, 12 Vet. App. 188, 195 (1999) (noting that generally "only the evidence in support of the claim is to be considered and generally a presumption of credibility attaches to that evidence in order to decide whether or not any VA claimant has sustained the claimant's burden of submitting a well-grounded claim under section 5107(a)") (emphasis in original). Nevertheless, the August 1995 VA medical examination failed to comply with the Board's March 1995 remand order for a medical opinion that would resolve the medical issues in the case and no other medical evidence of record resolves those issues, and therefore the claim must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). Concerning this, the Board notes that there is no evidence that the August 1995 VA examiner reviewed the service medical records, including the 1989 mammogram report, and, with regard to the Board's order to render an opinion on whether the findings on that report or other service medical records reflected an increase in the severity of the breast disease beyond the normal progress of the disease, the examiner merely stated that the disease increased "according to the [veteran], in relation to the running that she did." See August 1995 VA examination report (emphasis added). The opinion of the veteran on this medical matter is of little, if any, probative weight. See Espiritu v. Derwinski, 1 Vet. App. 492, 494 (1992). The Board requires the opinion of a doctor who will examine all the medical evidence in the file pertaining to this claim and render an informed medical opinion on this matter which provides a rationale for the conclusions reached and which demonstrates consideration of the nature of the breast disease present in this case and the history of its course as depicted in the medical reports of record. Whether The Decision To Sever Service Connection For Vaginitis Effective April 30, 1999, Was Correct. Background. Medical records from the veteran's service in the United States Army Reserves reflect that a pelvic examination conducted in connection with the veteran's enlistment for the Army Reserves in October 1976 was within normal limits. On a February 1983 examination, conducted while the veteran was enlisted in the reserves, the clinical evaluation on vaginal- pelvic examination was normal. The veteran was seen in June 1985 for complaints of a vaginal discharge. The assessment was monilial vaginal discharge. In October 1985, she was seen with complaints of vaginal discharge for one month. The assessment was "yeast (candidiasis vaginalis)". In November 1985, she was seen with complaints of menstrual cramps. The assessment was menstrual cramping and yeast infection. In November 1988 -- after entrance onto active duty in October 1987 -- the veteran was seen for complaints of a vaginal discharge off and on for one year. Objectively the pelvic examination was within normal limits. The assessment was history of vaginitis. In January 1989, the veteran was treated for urinary tract infection and a vaginal yeast infection. She was seen again with an assessment of monilial vaginitis in March 1989. Breast and pelvic examination was normal. A Pap smear was normal. In June 1989, the veteran complained of a yeast infection. The assessment was yeast vaginitis. She was treated for urinary tract infections in July and December 1989. In July, the examiner prescribed Monostat 7 "for biopsy-induced yeast infection." In January 1990, the veteran was seen again for a vaginal discharge. The assessment was nonspecific vaginitis. On July 1991 VA examination, the examiner noted the veteran's history of vaginitis in service, the history of current symptoms, and current ongoing treatment at another VA facility. The veteran was menstruating at the time, so no examination, including a Pap smear, could be performed. Nevertheless, the examiner diagnosed ongoing vaginitis, with vaginal discharge, under treatment. In a September 1991 rating decision, the RO granted service connection for vaginitis and assigned a 10 percent disability rating for that disorder. The veteran appealed the initial assignment of a 10 percent rating to the Board. In an October 1991 VA outpatient treatment report, it was noted that the veteran complained of a creamy, yellow vaginal discharge for a few months. There was no itching, burning, or abdominal pain. Objective findings on examination are illegible on the handwritten report. The diagnosis was vaginitis and the plan was a gynecological consultation. In a November 1992 rating decision, the RO confirmed and continued the 10 percent rating for service-connected vaginitis, noting "There was some evidence of vaginal discharge, moderate in degree . . . ." In March 1995, the Board remanded the claim for an examination "to determine the current severity of the veteran's service-connected vaginitis." On August 1995 VA gynecological examination, the examiner noted the veteran's history of vaginitis having been diagnosed in service in 1988. The veteran reported that she had an ongoing discharge basically all the time. She reported that a cream helped but that a discharge was always present. She had no itching, burning, or odor. The examiner noted that the service medical records showed that vaginitis had been diagnosed on several different occasions, usually monilial vaginitis, and that she had been treated with Monistat or other antifungal medications. On gynecological examination, Bartholin, urethral, and Skene's (BUS) glands had no rash. There was a scant whitish discharge on the perineum. Vault had a very scant whitish discharge. Cervix was parous and had a large cervical polyp. No lesions were noted. A test was done which reflected scant yeast. Wet prep was normal. GC and chlamydial cultures were done. Pap smear was obtained. On examination, the cervix was friable and a polyp was friable, both bled quite easily. The uterus was anteverted, anteflexed, mobile, and nontender. Adnexa was mobile and nontender bilaterally with no palpable masses. The assessment was cervical polyp; mild yeast vaginitis which appeared to be recurrent by the veteran's history. The examiner noted that a fasting blood sugar would be obtained to rule out diabetes as a cause for recurrent monolial vaginitis and that no other cause of vaginitis was noticed at that time. A September 1995 VA Pathology Report showed the results of a cervical-vaginal smear. The diagnosis was benign cellular changes, inflammation, and trichomomas vaginalis. An endocervical polyp was removed. In a May 1996 rating decision, the RO proposed to sever service connection for vaginitis, noting, "A thorough review of the veteran's service medical records show she was treated for this condition on several occasions prior to her entry on active duty in 1985 and 1986", and stating, "Condition clearly existed prior to enlistment on active duty and no aggravation is shown to have occurred." The RO further stated, "It was a clear and unmistakable error initially to service connect this condition with the prior history of many episodes of similar infections." The veteran was initially notified of the proposal to sever service connection in a May 1996 supplemental statement of the case where it was included along with other claims which the veteran already had appealed to the Board. However, no pertinent regulations, including section 3.105(d), pertaining to the severance were included in the supplemental statement of the case. Moreover, a covering letter accompanying the supplemental statement of the case instructed the veteran that response to it was "optional." In June 1996, the RO received a letter from the veteran requesting copies of all medical records that the rating board used in making its decision, "especially medical records dated in 1985 and 1986 concerning when and where I was treated for vaginitis on several occasions prior to active duty." On June 27, 1998, the RO received VA Form 21-4138, Statement in Support of Claim, on which the veteran stated, "I disagree with the [RO] decision on my disability claim." This statement was accompanied by various medical records highlighted in yellow and interspersed with statements from the veteran including one statement which specifically disagreed with the proposal to sever service connection for vaginitis. She stated in pertinent part, Concerning vaginitis in 1985-1986, I had recurrent [urinary tract infections] which was caused from washing with soap and water after each urination. I was given an antibiotic which left me with a yeast infection. In 1986 while on active duty, I went swimming on post I caught a fungus infection and was instructed by the doctor on post to stay out of pools, bathing in bathtubs, and to stop washing every time I urinate. I was given Flagel and vaginal cream. There are several reasons why women have various discharg (sic), and I totally disagree with your request to sever this claim. In a letter dated August 13, 1996, the RO notified the veteran -- in a notification letter -- of the May 1996 rating decision proposing to sever service connection for vaginitis effective November 1, 1996, and of her appeal rights in this regard. An August 1997 decision severed service connection for vaginitis, effective November 1, 1997. In a letter dated August 26, 1997, the RO notified the veteran of the severance of service connection for vaginitis effective November 1, 1997, and of her appeal rights in this regard. At a hearing before a VA hearing officer in October 1997, the veteran testified that she opposed the severance of service connection for vaginitis because she still had the same condition that she had in service, because she got vaginitis in service from an antibiotic given to her to treat urinary tract infection, and because there are "many different discharges that a woman can have". A February 1999 rating decision changed the effective date of the severance of service connection for vaginitis from November 1, 1997, to April 30, 1999. In a February 1999 supplemental statement of the case, the RO noted in this regard, The condition clearly existed prior to enlistment on active duty and no aggravation is shown to have occurred. It was clear and unmistakable error to initially service connect this condition with the prior history of many episodes of similar infections without evidence of aggravation beyond normal progression. Due process was provided the veteran by separate letter dated August 13, 1996, predicated on the rating decision dated May 15, 1996. That decision proposed to sever service connection for vaginitis based on a clear and unmistakable error. The Adjudication Officer approved this severance. However, the rating decision of 8-14-97, which severed service connection for vaginitis, is hereby revised on the basis of clear and unmistakable error (38 CFR 3.105(a)). The veteran requested a hearing within 30 days of the notification of the proposal to sever which prohibits further action until the hearing is held or canceled. The effective date of this revised rating corresponds to the date from which benefits would have been payable if the former decision had been correct (2 months from today's notification). In the February 1999 supplemental statement of the case, regulations pertaining to a severance of service connection, including section 3.105(d), were provided to the veteran for the first time. A March 19, 1999, covering letter accompanying the supplemental statement of the case provided, This is in further reference to the appeal you have filed from our decision on your claim for benefits. It is not a decision on the appeal you have initiated. It is a Supplemental Statement of the Case which contains changes or additions to the original Statement of the Case sent to you on May 22, 1992. Before returning your records to the Board of Veterans' Appeals, we are giving you a period of 60 days to make any comment you wish concerning the additional information. A response at this time is optional. If we receive no additional information from you within 60 days, we will return your records to the Board of Veterans' Appeals for review of the issues on appeal, and the Board of Veterans' Appeals will provide you with a copy of its decision. If you feel that you have stated your case completely, you should let us know so that we may forward your appeal to the Board without waiting for the 60 day period to expire. See March 19, 1999, letter accompanying the February 1999 supplemental statement of the case (emphasis added). The veteran did not perfect her appeal to the Board by filing a VA Form 9 substantive appeal after being provided for the first time in the February 1999 supplemental statement of the case notice of the regulations pertaining to the severance of service connection for vaginitis. Analysis. An appeal to the Board of a decision by the RO is accomplished in a three-step sequential process. Specifically, (1) the veteran initiates an appeal by filing a notice of disagreement with the decision, (2) the RO issues a statement of the case providing the veteran notice of the laws and regulations pertaining to the decision, the evidence that was considered in making the decision, and the reasons for the decision; and (3) the veteran perfects or completes the appeal to the Board by filing a VA Form 9 substantive appeal in response the statement of the case. 38 U.S.C.A. § 7105(a), (c), (d) (West 1991) ("Appellate review will be initiated by a notice of disagreement and completed by a substantive appeal after a statement of the case is furnished . . . ."); 38 C.F.R. § 20.200 (1996); Roy v. Brown, 5 Vet. App. 554, 555 (1993); cf. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997) (Archer, J., concurring) ("The claimant, in order to perfect an appeal to the BVA, 'should set out specific allegations of error of fact or law, such allegations related to specific items in the statement of the case.'") (quoting 38 U.S.C. § 7105(d)); 38 C.F.R. § 20.202("Board may dismiss any appeal which fails to allege specific error of fact or law in the determination, or determinations, being appealed); but see Rowell, 4 Vet. App. at 17 (holding that lack of timely filed substantive appeal does not deprive Board of jurisdiction over appeal initiated by a timely notice of disagreement); Beryle v. Brown, 9 Vet. App. 24, 28 (1996) (holding that, where Board proceeded to review claims on appeal where no substantive appeal was filed, Board implicitly waived the filing requirement of the substantive appeal as to those claims). In this case, the veteran filed a timely notice of disagreement in June 1996 after receiving notice of the decision proposing to sever service connection for vaginitis in the May 1996 supplemental statement of the case. In response to the notice of disagreement, the RO should have issued a statement of the case. If the statement of the case is incorporated with a supplemental statement of the case pertaining to other claims for which appeals have already been completed, the RO must inform the veteran to complete the appeal of any new issues contained in the supplemental statement of the case. 38 U.S.C.A. § 7105(d)(3); 38 C.F.R. § 2.302(c). The RO incorporated the severance issue in this case in the February 1999 supplemental statement of the case that also concerned other issues already on appeal. However, instead of informing the veteran that she should file a VA Form 9 with the new issue of severance of service connection for vaginitis, it informed her that a response was optional. The veteran did not file a VA Form 9 substantive appeal within 60 days of the February 1999 supplemental statement of the case. To ensure the veteran's rights of due process, the Board generally would remand a case such as this and give the veteran an opportunity to submit a substantive appeal to perfect her appeal to the Board if no document was in the file that could be construed as a substantive appeal. However, the Board may extend the 60-day time period for the filing of the VA 9 for good cause shown. 38 U.S.C.A. § 7105(d)(3) (West 1991). In this case, the veteran's representative included the severance issue on a June 1999 VA Form 1-646. Although not filed within the requisite time period, the Board construes this document as a timely filed VA Form 9 because the RO's advising the veteran that response to the supplemental statement of the case was optional constitutes "good cause" for her not having timely submitted a substantive appeal. Although the veteran's representative did not include a detailed argument on the severance issue in the VA Form 1-646, the Board concludes that the veteran will not be prejudiced because Board is deciding the severance issue in the veteran's favor. Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993). Once service connection has been granted, it can be severed only upon VA's showing that the rating decision granting service connection was the product of clear and unmistakable error (CUE) and only after certain procedural safeguards have been met. Daniels v. Gober, 10 Vet. App. 474, 478 (1997); 38 C.F.R. § 3.105(d) (1999). VA's burden in severing service connection is the same as a claimant's burden in attempting to overturn a final decision on the basis of CUE. Daniels, 10 Vet. App. at 478, citing Baughman v. Derwinski, 1 Vet. App. 563 (1991) and Graves v. Brown, 6 Vet. App. 166, 170-71 (1994) (holding that CUE is defined the same under section 3.105(d) as it is under section 3.105(a)). In this case, because the veteran filed a timely appeal of the rating decision which severed service connection, the Board must review the May 1996 rating decision to see if VA met the burden of showing that the September 1991 rating decision which granted service connection was based on CUE. In order to establish CUE in the September 1991 rating decision granting service connection for vaginitis, the RO must do more than disagree with the way the facts were weighed or evaluated by the adjudicators who granted service connection in the prior rating decision. See Russell v. Principi, 3 Vet. App. 310, 313 (1992). "CUE is a very specific and rare kind of 'error.' It is the kind of error, of fact or of law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error." Fugo v. Brown, 6 Vet. App. 40 (1993). Errors that are "clear and unmistakable" are undebatable; that is, reasonable minds could only conclude that the original decision was fatally flawed at the time it was made. Id. The RO granted service connection for vaginitis in a September 1991 rating decision without providing any reasons or bases for its decision although it did note evidence that it had relied on in making its decision. For example, the September 1991 rating decision noted, "Review of the service medical record shows veteran was seen on numerous occasions with complaints of vaginal discharge which was treated with various creams." In the May 1996 rating decision, which articulated the rationale for severance of service connection, the RO noted, "A thorough review of the veteran's service medical records that she was treated for this condition on several occasions prior to her entry on active duty in 1985 and 1986." The May 1996 rating board concluded, "Condition clearly existed prior to enlistment on active duty and no aggravation is shown to have occurred." The RO further stated, "It was a clear and unmistakable error initially to service connect this condition with the prior history of many episodes of similar infections." Thus, the May 1996 RO premises its decision of CUE in the September 1991 rating decision on two factual matters. First, that vaginitis existed prior to active service, and second, that the preexisting disorder was not aggravated in service. With regard to the first proposition, the evidence clearly shows that the veteran was treated for vaginitis in June and October 1985 which was prior to her entry onto active duty in October 1987. However, assuming, without deciding, that the vaginitis did exist prior to active service, the evidence of record is unclear as to whether treatment for vaginitis and yeast infections, referred to on one occasion in June 1989 as "yeast vaginitis", during the period of active duty from October 1987 to January 1990 constituted mere flare-ups of the preexisting condition or an aggravation of the underlying disorder beyond the natural progress of the disease. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991) ("Intermittent flair-ups during service of a preexisting injury or disease are not sufficient to be considered 'aggravation in service' unless the underlying condition . . . is worsened."). Given the several occasions of treatment for vaginitis in service, a finding of fact that these recurrences did not constitute aggravation is a finding of medical fact, requiring the adjudicator to base the finding on medical evidence of record that is dispositive or probative of the matter. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The Board finds no such medical evidence in the record on which to base a finding either that the preexisting disorder was aggravated in active service or that it was not aggravated in active service. Accordingly, it cannot be said that a determination that a preexisting vaginitis was aggravated during active service constituted clear and unmistakable error based on the factual record as it now stands. Venturella, 10 Vet. App. at 343. Since clear and unmistakable error in the September 1991 rating decision granting service connection for vaginitis is not shown, the severance of service connection for vaginitis was error, and service connection for vaginitis must be restored. A Rating Higher Than 10 Percent For Left And/Or Right Knee Chondromalacia. Background. Included in the service medical records is an Emergency Services Record from a private hospital, dated in December 1987, showing the following instructions: "No strenuous exercise using your knees until you are checked by an orthopedic surgeon at the base." Service medical records reflect that in December 1987 the veteran was seen with complaints of left knee problems. The assessment was chondromalacia patella. (Chondromalacia patellae is "softening of the articular cartilage of the patella; may cause patellalgia." Stedman's at 332. Patellalgia is "a painful condition involving the patella." Stedman's at 1311.) In January 1988, the veteran was referred to a service department orthopedic/podiatry clinic with complaints of chronic bilateral knee pain, left greater than right, since December 1987. She had edema bilateral knees with increased pain and was getting no relief from isometric exercises. She was examined by a physician whose assessment was bilateral knee semimembranous tendonitis and minimal lateral subluxation left and right patella. A January 1988 Physical Therapy Consultation report showed that the veteran had been in a quad strengthening program for two weeks for complaints of constant pain in the knees since December. The assessment was "[b]ilat[eral] knee semimembranous tendonitis (per MD)". On January 16, 1988, the veteran was admitted to a service department hospital for two days with the diagnosis of chondromalacia. No procedures were performed. Condition upon release was "improved." In late February 1988, the veteran was seen with complaints of persistent knee pain. Objectively, there was boggy medial aspect bilateral knees, negative McMurray's sign, negative Lachman's sign, and full range of motion. (McMurray's test is "rotation of the tibia on the femur to determine injury to the meniscal structures." Stedman's at 1780. Lachman's test is "a maneuver to detect deficiency of the anterior cruciate ligament; with the knee flexed 20 to 30 degrees, the tibia is displaced anteriorly relative to the femur; a soft endpoint or greater than 4 millimeters of displacement is positive (abnormal)." Stedman's at 1780.) The assessment was fat pattern/distribution vs. questionable pathology. In early March 1988, the veteran was seen in a service orthopedic/podiatry clinic for bilateral knee pain. It was noted that she had been doing better with exercises. Objectively, there was tenderness at the posterior popliteal area on the right. There was no instability. The assessment was to change her profile to walk aerobics or run at own pace. The veteran was to continue with exercises and start leg lifts. The next day, she was examined in an orthopedic/podiatry clinic. Objectively, there was minimal patellofemoral crepitus. There was tenderness of the patellar tendons. X-rays were normal. The assessment was arthritis vs. tendonitis/bursitis. In late March 1988, an assessment was tendonitis/chondromalacia bilateral knees. The veteran was given a physical profile of no running, marching, aerobics and no weight carrying over five pounds. In May 1988, the veteran was seen in an emergency room with a history of knee pain and swelling. Climbing or descending stairs increased the pain and swelling. She was referred to the orthopedic clinic for a consultation and evaluation of fitness for duty. The next day, the veteran was seen in the orthopedic clinic. Objectively, the left knee demonstrated a positive patellar grind with apprehension and positive crepitus. There was no effusion or capsular tenderness. There was an inferior shift of the patella. The left knee was the same as the right except that there was no patellar shift. The assessment was left greater than right patella femoral degenerative joint disease/Grade II chondromalacia. The plan included a profile, medication and a leg brace on the left. Later in May 1988, the veteran was seen again in the emergency room for complaints of left knee pain. She was referred to the orthopedic clinic. Physical examination reflected positive patellar facet tenderness, no effusion, and full active range of motion. It was also noted, "[I]ncreased Q angle -- has bilateral valgus." X-rays were within normal limits. The impression was left knee pain -- probably chondromalacia. The treatment plan included a profile, crutches, and a knee immobilizer. The next day, she was seen again in the emergency room. It was noted that she had a chronic left knee problem aggravated by field assignment and that she had been seen multiple times secondary to increased pain. It was noted that she was on a profile but that it was not restrictive enough. She complained of increased pain and swelling. On physical examination, the left knee had decreased range of motion. There was tenderness over the medial jointlines bilaterally. The joint was stable. There was mild effusion. The assessment was left knee pain secondary to chondromalacia/rule out torn cartilage. The plan was a profile, follow-up with orthopedics, and continue with medications. In late May 1988, the veteran was seen with a request for a review of her records to determine whether she currently had a profile. Objectively, there was no increased heat bilaterally in the knees and no effusion. There was positive synapatellar bursa bilaterally. Range of motion was full. The veteran was on crutches with a right hinged knee brace and a left knee immobilizer. The assessment was chondromalacia. The profile dated May 20th was current and stated the restrictions. The plan was to continue Motrin, crutches, braces, and immobilizer as indicated. In June 1988, the veteran was admitted to a service department hospital for four days. She presented with a five month history of bilateral knee pain, left greater than right. She stated that the pain came on suddenly one month after starting aerobic exercises. She reported no specific trauma to the knees. She complained of continuous left knee pain with the right knee having gotten better. She had some night pain and pain going up and down stairs. She reported having been on a physical profile at her home base since March to limit running and marching. She was on a physical therapy regimen and taking anti-inflammatory drugs and had some relief of her symptoms. Her knee pain had been improving until she started summer camp in the middle of May. Since that time she had had some significant knee pain. On physical examination of the left knee, there was no effusion. Range of motion was from 0 to 130 degrees. There was tenderness over the medial joint line which was not exacerbated by McMurray's testing. There was some retropatellar tenderness. There was no ligamentous laxity. There was no collateral-ligamentous laxity. Drawer and Lachman's signs were negative. (Drawer sign is, "in a knee examination, the forward or backward sliding of the tibia indicating laxity or tear of the anterior (forward slide) or posterior (backward slide) cruciate ligaments of the knee." Stedman's at 1616.) Examination of the right knee showed no effusion. There was positive retropatellar tenderness. Range of motion was from 0 to 130 degrees. Drawer and Lachman's signs were negative. There was no collateral-ligamentous laxity. X-rays of the knees bilaterally were within normal limits. The diagnosis was bilateral patellofemoral joint syndrome. It was not felt that surgical treatment was needed at the time but that conservative treatment might be of some benefit. The veteran was given a temporary profile to September 1988 which prohibited running, continuous stair climbing, deep knee bends, and jumping. A Physical Therapy Consultation report reflected continued physical therapy throughout 1988. In August 1988, the veteran reported for a refill of medication for bilateral patellofemoral syndrome. Objectively, the knees were stable bilaterally with mild peripheral edema and mild to moderate swelling over inframedial patella bilaterally. Also in August 1988, a whole body bone scan was done with attention to the patellae. The impression was a normal whole body bone scan. In September 1988 the veteran reported pain in the left knee. Objective findings were negative except for mild bilateral infrapatellar tenderness. The assessment was bilateral patellofemoral syndrome. In late November 1988, a physician recommended an arthrogram. However, in December 1988, the veteran reported that bilateral knee pain had improved with quad exercises. Objectively, there was no pain to palpation over the knee. It was decided to reevaluate the knees in six months. In early March 1989, a physical profile serial report showed that the veteran was scheduled for release from temporary restriction in June 1989 and "may walk aerobics or run at own pace." The assessment was status post bilateral knee pain chondromalacia. In late March 1989, the veteran was seen for complaints of pain and swelling of bilateral knees and feet for one year. The examiner noted that she walked without an antalgic gait and that there was a long history of recurrent diagnosis of chondromalacia without other pathological findings. The veteran stated she could not do physical training and desired a profile. Findings on physical examination of the knees by a doctor were normal including range of motion testing which was from 0 to 140 degrees bilaterally. The impression was chondromalacia bilateral and ankle pain. The treatment plan was quad exercises and Motrin, and the veteran was returned to duty. There were no further complaints or findings pertaining to the knees prior to the veteran's separation from service in January 1990. On a July 1991 VA Compensation and Pension examination report, it was noted that the veteran complained of pain in both knees. She reported that she had been evaluated for arthritis but that it had not been found and she had been told she had chondromalacia of the patella. On examination, the veteran had very lax patellas which were easily dislocatable bilaterally. The dislocatability appeared much more medial than lateral. There was a 10-12 degree valgus defect at the knee joint bilaterally. The knee range of motion was normal. There was approximately 15 degree medial- lateral instability which was symmetric. Lachman's sign was negative as were the anterior and posterior drawer signs. There were no joint effusions palpable. She had a normal thyroid. Neurologically, the reflexes were 2+ and symmetric. Muscle strength was 5/5 and the sensory, nonfocal. The assessment was bilateral patellofemoral joint syndrome. No arthritis was found, although laboratory results were pending. An October 1992 VA outpatient Consultation Sheet shows that the veteran was referred from an orthopedic clinic to a physical therapy department for bilateral lower extremity conditioning, especially straight leg raising, quad sets. The examiner noted that the veteran complained of bilateral knee pain since 1987. The veteran noted an increasing valgus deformity, periodic effusions, much popping, but no instability or "giving way". On physical examination, there was no instability, no effusion. There was a slight valgus deformity bilaterally, the right greater than the left. The examiner noted a high riding right patella, slight lateral displacement with flexion. The impression was degenerative joint disease, valgus deformity with patellofemoral pain. A February 1993 letter from a VA physician states that the veteran was being seen in VA clinics for "problems of arthritis of the knees." The doctor stated that running and any exercise may aggravate the symptom of pain. On August 1995 VA Orthopedic examination, the veteran gave a history of aching pain in her knees beginning in November 1987 while she was doing aerobics. She reported that the pain had been around both her knee caps and that chondromalacia patella was diagnosed. She also reported she was told that she had arthritis of the knees. Her present complaints were aching and discomfort at the end of the day after she had been walking around a lot. She stated that sometimes there was some swelling. She denied increased pain on walking up and down stairs but said that she sometimes felt that her knees might pop out or dislocate. She stated that her knees popped and grate a lot. On physical examination, there was full and complete range of motion of the knees from 0 to 135 degrees. The examiner noted that the veteran had obvious knock-knees in that, with her knees touching each other, her ankles were three inches apart. She had some malalignment of the patella in that it moved from the medial side to the lateral side as she flexed and extended her knee. There was no effusion. The ligaments were strong and intact without evidence of ligamentous laxity or instability. McMurray's test and pivot shift test were negative bilaterally. There was no evidence of internal derangement. Examination of both patellae revealed them to be somewhat small and mildly hypermobile. She had a chondromalacia of 1+ on the left to compression over the underlying femoral condyle and a mildly positive patellofemoral quadriceps jerk test on the left. She had a trace of chondromalacia on the right with a negative jerk test. The diagnosis was patellofemoral syndrome with 1+ chondromalacia on the left and trace on the right. The examiner stated that no abnormalities of the knees were noted other than the congenital and developmental bilateral mild valgus deformity (knock-knees). The examiner noted that the congenital knock-knees condition usually predisposed a person to chondromalacia and patellar tracking problems. At a hearing before a VA hearing officer in October 1997, the veteran testified that she had never fallen due to her knees and that there was no instability but that sometimes they felt as if they are going to lock, as in service. They made a popping and cracking sound if she got up from a sitting position on the floor or sometimes from a chair. She walked eight hours a day on her job and her knees hurt at the end of the day. She testified that she felt she should be rated 10 percent for each knee. June 1998 x-rays of the knees showed no gross abnormality. On June 1998 VA orthopedic examination, the veteran gave a history of the onset of knee problems in 1987. She was treated for patellofemoral syndrome and, according to the examiner, service medical records showed that degenerative joint disease and chondromalacia were also diagnosed. The veteran reported she had pain climbing or descending stairs and had difficulty with repetitive squatting or prolonged sitting, with discomfort along the anterior aspect of both knees. The only assistive device she used was a wraparound knee brace. She had not had any orthopedic surgical procedures. There were no episodes of dislocation or subluxation. She did not have any constitutional symptoms suggestive of inflammatory arthritis. On physical examination, heel and toe gait was normal. Neurological review of the lower extremities showed brisk deep tendon reflexes, no evidence of muscle wasting, no evidence of significant weakness, and no sensory changes. There was mild patellofemoral crepitus of the knees. The apprehension sign with patellofemoral translation was negative. The patellofemoral joint translated easily over the lateral femoral condyle and was not pathologic. Range of motion of both knees was 0-140 degrees. Ligamentous stability to anterior and posterior cruciate ligament testing was normal. Collateral ligaments were intact, and there was no joint line tenderness. McMurray's test was negative in both knees. The examiner noted that an August 1988 bone scan (to include the patella) and x-rays of both knees were negative. Chondromalacia patella, bilateral with mild retropatellar pain, was diagnosed. The examiner commented that the current knee symptoms appeared unrelated to any significant localized pathology. Analysis. In a September 1991 rating decision, the RO awarded service connection for chondromalacia, both knees, and assigned an initial rating of 10 percent for that disorder effective as of January 27, 1990, the day after the date the veteran was discharged from service. The veteran appealed the initial assignment of the rating to the Board, and in March 1995, the Board remanded the case for further development of the evidence including another examination. On remand, the RO continued the 10 percent rating for both knees in a May 1996 rating decision. In a February 1999 rating decision, the RO assigned a 10 percent rating for the service-connected chondromalacia for each knee -- left and right -- and made both 10 percent ratings effective from January 27, 1990. Accordingly, the issues on appeal now concern the entitlement to initial disability ratings higher than 10 percent for chondromalacia of each knee. Disability ratings are intended to compensate reduction in earning capacity as a result of the specific disorder. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such disorder in civilian occupations. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). In considering the severity of a disability it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (1999). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (1999); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, they do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In Fenderson v. West, 12 Vet. App. 119 (1999), the Court noted, in pertinent part, that there is a "distinction between an original rating and a claim for an increased rating" and that this distinction "may be important . . . in terms of determining the evidence that can be used to decide whether the original rating on appeal was erroneous . . . ." Fenderson, 12 Vet. App. at 126 (emphasis in original). In Fenderson, the Court held that the rule articulated in Francisco v. Brown did not apply to the assignment of an initial rating for a disability following an initial award of service connection for that disability. Fenderson, 12 Vet. App. at 126; Francisco, 7 Vet. App. at 58. As noted above, the Court held in Francisco that, although VA regulations require review of the entire recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over current medical findings and that, where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Instead, in Fenderson, the Court held that, where a veteran appealed the initial rating assigned for a disability, "staged" ratings could be assigned for separate periods of time based on facts found. Fenderson, 12 Vet. App. at 126. Concerning this difference, the Court stated that the distinction "may be important . . . in terms of determining the evidence that can be used to decide whether an original rating on appeal was erroneous . . . ." Id. In addition, the Court concluded in Fenderson that the RO did not provide the appellant with a correct statement of the case (SOC) concerning an issue because in addressing that issue the RO "mistakenly treated the ......claim as one for an '[i]ncreased evaluation ..... rather than as a disagreement with the original rating award, which is what it was." Fenderson, 12 Vet. App. at 132. (emphasis in the original). The Court indicated that "this distinction is not without importance in terms of VA adjudicative actions," and remanded the matter for a SOC. Id. The Board concludes that this case may be distinguished from Fenderson with regard to the SOC because in the May 1992 SOC the RO identified the issues on appeal not as claims for an "increased" disability rating for chondromalacia of the knees but rather as "Evaluation of" chondromalacia of the knees. More important, the RO's May 1992 SOC provided the appellant with the appropriate applicable regulations and an adequate discussion of the basis for the RO's assignment of the initial disability evaluations for the service-connected condition of the knees. With regard to the evidence that should be considered concerning an appeal of an initial rating, the Board notes that by taking such an appeal, the veteran is disagreeing with the RO's assessment of the degree of disability present at a time contemporaneous with the claim for service connection for the disability and with the rating decision which assigned the initial rating. Therefore, evidence contemporaneous with that period of time will have more probative weight than evidence dated a long time before or after that period of time. In this case, the claim for service connection for a disability of the knees was filed in December 1990 and the initial rating was assigned in the September 1991 rating decision. Therefore, medical evidence contemporaneous to that time will be inherently more probative than, for example, service medical records showing the degree of disability of the knees that was manifested in 1988 or 1989 because VA compensation is awarded for the current degree of disability and not for a degree of disability which existed in the past. If the evidence dated after the period of time contemporaneous to the claim and assignment of the initial rating shows that chondromalacia of the knees increased or decreased enough to warrant a higher or lower rating under the criteria in the VA Schedule for Rating Disabilities, the Court's opinion in Fenderson states that "staged" ratings may be assigned for separate periods of time based on facts found. Fenderson, 12 Vet. App. at 126. The VA Schedule for Rating Disabilities provides no criteria for evaluating the degree of disability resulting from chondromalacia, and therefore, the RO rated the veteran's service-connected chondromalacia analogously to tenosynovitis which is inflammation of a tendon and its enveloping sheath. 38 C.F.R. §§ 4.20, 4.27, 4.71a, Diagnostic Code 5099-5024 (1999); Stedman's at 1771. Tenosynovitis is rated on limitation of motion of the affected part, as arthritis, degenerative, under Diagnostic Code 5003. 38 C.F.R. § 4.71, Diagnostic Code 5024 (1999). The Board notes that this analogous rating is appropriate because chondromalacia is a softening of cartilage and degenerative arthritis, which is synonymous with osteoarthritis, is "characterized by erosion of articular cartilage . . . which becomes soft, frayed, and thinned . . . ." Stedman's at 149, 1267; see Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992) (Board should provide an explanation for a diagnostic code used for a disorder that must be rated analogously to another disorder). Arthritis is rated as follows: Degenerative arthritis established by X- ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint . . . affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. . . . 38 C.F.R. § 4.71a, Diagnostic Code 5003 (1999). For the purpose of rating disability resulting from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (1999). The rating schedule provides ratings under Diagnostic Code 5003 for degenerative arthritis shown by x-ray where there is an absence of limitation of motion, but the schedule specifically prohibits the assignment of those ratings for tenosynovitis. See 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 2 (1999). Normal range of motion of the knee for VA rating purposes is from 0 to 140 degrees. 38 C.F.R. § 4.71, PLATE II (1999). Ratings are assigned for certain degrees of limitation of motion as follows: Flexion limited to 15 degrees.........................30 Flexion limited to 30 degrees................................20 Flexion limited to 45 degrees............................10 Flexion limited to 60 degrees.............................0 Extension limited to 45 degrees.....................50 Extension limited to 30 degrees......................40 Extension limited to 20 degrees..........................30 Extension limited to 15 degrees......................20 Extension limited to 10 degrees......................10 Extension limited to 5 degrees..........................0 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (1999). In this case, the last treatment notations from the service medical records -- and the ones most contemporaneous with the veteran's December 1990 claim and the RO's September 1991 rating decision -- are dated in March 1989, the first a physical profile serial report showing that the veteran was scheduled for release from temporary restriction in June 1989 and "may walk aerobics or run at own pace." The second notation showed that the veteran was seen for complaints of pain and swelling of bilateral knees for one year, stating that she could not perform physical training and requesting a profile. The examiner noted that she walked without an antalgic gait and that there was a long history of recurrent diagnosis of chondromalacia without other pathological findings. Findings on physical examination of the knees by a doctor were normal, including range of motion testing which was from 0 to 140 degrees bilaterally. The treatment plan was quad exercises and Motrin, and the veteran was returned to duty. There were no further complaints or findings pertaining to the knees prior to the veteran's separation from service in January 1990. On July 1991 VA examination -- the examination most probative in determining whether initial disability rating higher than 10 percent for each knee should have been assigned -- range of motion of the knee was described as normal. With the exception of the finding of the patellar shift -- which the Board discusses in more detail below -- chondromalacia of the knees was manifested by complaints of pain with normal range of motion. The range of motion demonstrated does not meet the requirements for a compensable rating under the criteria for assessing limitation of motion of the part affected, i.e., the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (1999). Thus, a 10 percent rating was assigned under criteria for degenerative arthritis. Although the criteria require that there be some limitation of motion to warrant a 10 percent rating and none was demonstrated in this case, the Board concludes that a 10 percent rating was appropriately assigned given the veteran's complaints of pain. See 38 C.F.R. § 4.59 (1999); VAOPGCPREC 9-98 at para. 4 (Aug. 14, 1998) ("[P]ainful motion is considered limited motion even though a range of motion is possible beyond where the pain sets in."); see also DeLuca v. Brown, 8 Vet. App. 202, 206- 08 (1995); 38 C.F.R. §§ 4.40, 4.45 (1999). There is no provision in the rating criteria for a higher disability rating than 10 percent based on limitation of motion where the range of motion is normal. Accordingly, the Board concludes that the RO appropriately assigned initial ratings of 10 percent for chondromalacia of each knee. With regard to whether the evidence in this case demonstrates that "staged" ratings should be assigned, the Board notes that the findings of examiners after July 1991 -- in October 1992, February 1993, August 1995, and June 1998 -- are consistent with those found in July 1991. The chondromalacia is shown to have been manifested by complaints of pain with full range of motion. On the most recent examination in June 1998, the chondromalacia of both knees was manifested by mild retropatellar pain and mild patellofemoral crepitus. Range of motion of both knees was 0-140. The examiner specifically noted that there was no evidence of muscle wasting, significant weakness, or sensory changes in the lower extremities. See DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. §§ 4.40, 4.45 (1996). Accordingly, the Board concludes that "staged" ratings are not required based on facts found in this case. Manifestations of chondromalacia of both knees have remained the same throughout. Finally, with regard to what examiners have described as a patellar "shift" or laxity, the Board notes that, in postservice medical reports, beginning with the July 1991 VA examination, examiners often noted shifting or laxity of the patellae, and their descriptions are fairly consistent both with each other and with the descriptions in service. The July 1991 VA examiner noted that the veteran had very lax patellas which were easily dislocatable bilaterally, that this dislocatability appeared much more medial than lateral, and that it was a 15 degree medial-lateral instability which was symmetric. In October 1992, a VA examiner noted a high riding right patella, slight lateral displacement with flexion. Similar to both these reports, an examiner in August 1995 noted some malalignment of the patella in that it moved from the medial side to the lateral side as she flexed and extended her knee. However, the Board notes that these examiners -- like the examiners in service -- also consistently noted that the knee joints themselves were stable, that the ligaments were strong and intact without evidence of ligamentous laxity or instability. See August 1995 VA examination. In this regard, on the latest examination report of record, a June 1998 VA orthopedic examination report, the examiner noted that the patellofemoral joint translated easily over the lateral femoral condyle "and was not pathologic." The examiner also noted that there was normal ligamentous stability, the collateral ligaments were intact, and that the veteran reported that there had been no episodes of dislocation or subluxation of the knee joints. Similarly, she reported that there was no instability or "giving way" to the October 1992 examiner and at the October 1997 hearing. Because the examiners in service and since service have consistently reported that there no subluxation or lateral instability of the knee joints themselves, the Board concludes that there is no basis for consideration of a separate rating for either knee under the criteria for rating recurrent subluxation or lateral instability of the knee under Diagnostic Code 5257. See, generally, VAOPGCPREC 9-98 (Aug. 14, 1998); VAOPGCPREC 23-97 (July 1, 1997). A Compensable Rating For Right Achilles Tendonitis,. Background. Service medical records reflect that the veteran was seen in January 1987 while serving with the Army Reserves with a complaint of a right foot injury. Notes on the Screening Note of Acute Medical Care included "tear anterior talo- fibular ligament [right foot]" and "possible partial rupture Achilles right foot." Objectively, range of motion was full and there was no swelling. There was tenderness over the Achilles and dorsum of the foot. The assessment was "strain". On active duty in December 1988, the veteran complained of right ankle tenderness. Objectively there was tenderness. In March 1989, she complained of bilateral foot pain. She reported swelling of the ankles at the malleoli and provided a history of injury to the right foot falling off a 21/2 ton truck in 1987. Objectively, there was full range of motion of both ankles without effusion. Varus stress and drawer signs were negative. The impression was ankle pain. In July 1991, the veteran was seen in a VA Podiatry Clinic for a Compensation and Pension examination. She reported that she had fallen from a height in January 1987 and ruptured her Achilles tendon. She stated that the injury required a three-month period of recuperation and that she was treated with nonsteroidal anti-inflammatory drugs but was not casted. She stated that at the present time she had problems running. Her employment was sedentary. She could still shop, dance, etc., and had pain only if exertion was high. Objectively, it was noted that she walked without a limp. Toe and heel walk was within normal limits. Ankle dorsiflexion was 12 degrees on the left and 10 degrees on the right and nonpainful. There was no palpable defect. Muscle strength was within normal limits. There was tenderness to palpation of the right Achilles tendon insertion. The assessment was a history of Achilles rupture -- partial, right foot/ankle. The examiner noted that, in light of range of motion and strength, it was probable that there had been only a partial rupture. There was mild tendonitis at present and no ankle pathology. A February 1993 notation from a VA Employee Health Clinic showed that the veteran, who was employed by VA, was seen for complaints pertaining to her right ankle after having slipped over a rug at home. On examination, there was moderate swelling and tenderness with passive range of motion. X-rays of the right ankle were normal. The impression was right ankle sprain. The plan was to refer the veteran to a private physician. On August 1995 VA Orthopedic examination, the examiner veteran gave a history of having injured her right ankle in service when she fell from a truck. She stated that she had ruptured a tendon and torn ligaments and was sent back from Europe on crutches. She reported that this incident occurred while she was on reserve duty and it was a private doctor who told her she had torn the tendon and ligaments. She reported she was treated with pills and rest, but had no other treatment such as a cast or splint, etc. Her present complaints were of pain and aching after prolonged walking and sometimes after wearing boots for a long period of time. The veteran did not describe any recurrent sprains or turning under of her ankles or any recurrent swelling, just some mild aching and discomfort about the right side. Physical examination of the ankle was entirely normal. There was full range of motion with 18 degrees of dorsiflexion and 45 degrees of plantar flexion, equal to that of the opposite ankle. Inversion and eversion were equal to that of the opposite ankle and there was no rocking of the talus with inversion stress. There was no pain elicited on rather forceful manipulation of the ankle, but there was some slight tenderness over one area of the Achilles tendon. There was no swelling or knot or other evidence of previous rupture of the Achilles tendon and all of the other tendons were palpable and intact to examination including all of the peroneal tendons and the posterior tibial and anterior tibial tendons. There was no effusion and there was no particular tenderness about the ankle joint. The diagnosis was old sprain/strain injury to the right ankle with no evidence of ruptured tendons and no evidence of residual laxity of the right ankle. The examiner noted, "Basically, the diagnosis [is] of the sprain of the right ankle, healed, without significant sequelae." At a hearing before a VA hearing officer in October 1997, the veteran testified that she did not have any swelling of the right ankle or Achilles tendon, that she had had some pain over the weekend before the hearing on the top side of her foot but that she was "fine" on the day of the hearing, and that she did not wear any type of brace on her ankle. On June 1998 VA orthopedic examination, the examiner recorded the veteran's history of problems with the right Achilles tendon in 1987. It was noted that she was on drill status with the reserves and fell off a 21/2 ton truck, experiencing a strain to her right Achilles tendon, which was treated as Achilles tendonitis. The veteran reported continued aching type of discomfort in the right heel and at the bottom of her leg, but she had some improvement in that symptom over the last several years. No assistive device was used for the right ankle. She had not had any orthopedic surgical procedures. There were no episodes of dislocation or subluxation. She did not have any constitutional symptoms suggestive of inflammatory arthritis. Physical examination of the right Achilles tendon showed no evidence of swelling. There was no localized tenderness. Range of motion of the ankle was 10 degrees of dorsiflexion, 45 degrees, plantar flexion. The veteran was able to maintain a "toe raise" gait pattern. Ankle ligaments were stable. The diagnosis was right Achilles tendonitis, resolved. Analysis. The summary of the Court's decision in Fenderson v. West, 12 Vet. App. 119 (1999), that applied to the issue of the initial rating for chondromalacia of the knees also applies to the initial noncompensable rating assigned for the ankle disorder and the Board will not repeat that summary here. As was the case with the knee claim, the May 1992 SOC did not phrase the issue as one for an increased rating but as one involving the "evaluation" of Achilles tendonitis, right. However, the RO provided the appellant with the applicable regulations and an adequate discussion of the basis for the assignment of the initial evaluations. The service-connected right Achilles tendonitis is evaluated analogously under criteria for evaluating injuries sustained to Muscle Group X. 38 C.F.R. § 4.73, Diagnostic Code 5399- 5310 (1999). The Board concludes that these criteria are appropriate for analogous consideration of Achilles tendonitis because Muscle Group X governs movements of the forefoot and toes and propulsion thrust in walking and concerns other important plantar and dorsal structures including certain ligaments and tendons of the foot. See Pernorio, 2 Vet. App. at 629 (Board should provide an explanation for a diagnostic code used for a disorder that must be rated analogously to another disorder). These rating criteria were revised during the pendency of this appeal with the revisions becoming effective in July 1997. In Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991), the Court held that, where a law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to appellant should and will apply unless Congress provides otherwise or permits the Secretary to do otherwise. The Board must remand cases for the RO to consider both versions of the law in the first instance unless the claimant will not be prejudiced by the Board's consideration of the claim under both the old and new criteria. VAOPGCPREC 11-97 at 3-4 (Mar. 25, 1997); Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993). In this case, the Board notes that the RO did consider the claim under both the old criteria -- as depicted in the May 1992 SOC -- and under the new criteria -- an abbreviated version of which was provided under the "Reasons and Bases" section of the February 1999 SSOC. Moreover, the veteran will not be prejudiced by review of this claim by the Board because the revisions to the rating criteria under Diagnostic Code 5310 involved merely a superficial rearrangement of the wording of the regulatory criteria and no substantive changes. Compare 38 C.F.R. § 4.73, Diagnostic Code 5310 (1991) with 38 C.F.R. § 4.73, Diagnostic Code 5310 (1999). Any argument for a higher rating that the veteran could have made under the "new" criteria could have been advanced under the "old" criteria as well. Accordingly, the Board concludes that the veteran will not be prejudiced by the Board's review of her claim on appeal because due process requirements have been met and remand is therefore unnecessary. VAOPGCPREC 11-97 at 3-4 (Mar. 25, 1997); Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993); Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991); see Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided); see also Winters v. West, 12 Vet. App. 203, 207 (1999) (en banc) (noting that "the law does not require a useless act".). The criteria under Diagnostic Code 5310 provide a noncompensable rating for a slight degree of disability; a 10 percent rating for a moderate degree of disability; a 20 percent rating for a moderately severe degree of disability and a 30 percent rating for a severe degree of disability. The regulations provide much information as to what constitutes slight, moderate, moderately severe, and severe levels of disability resulting from muscle injuries, especially through and through wounds of the muscles caused by gunshot or shrapnel or injuries to muscles and tendons caused by open, comminuted fractures. 38 C.F.R. § 4.55, 4.56. For VA rating purposes, the cardinal signs and symptoms of muscle disability are the loss of power, weakness, lowered threshold of fatigue; fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c) (1999). The regulations also provide detailed criteria for classifying the disability rated under Diagnostic Codes 5301 through 5323, including Diagnostic Code 5310, as slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56(c) (1999). Here, the disability resulting from a strain of the right Achilles tendon does not begin to approach the criteria for a rating of moderately severe or severe, which contemplate injuries comparable to those rendered by through and through or deep penetrating wounds of missiles with a history of prolonged hospitalization or periods of treatment and indications of loss of deep fascia and positive evidence of impairment on tests of strength and endurance. 38 C.F.R. § 4.56(d)(3), (4) (1999). Accordingly, the Board concludes that such ratings are not warranted and will consider whether the evidence shows that an initial rating for a moderate degree of disability, rather than for a slight degree of disability, is warranted. In this regard, the criteria provide, (1) Slight disability of muscles--(i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles--(i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(1), (2) (1999). The veteran's right Achilles tendonitis produces no more than a slight degree of disability. Objective findings on the July 1991 VA examination -- the examination most contemporaneous with the claim in December 1990 -- show that the right Achilles tendonitis was manifested by nonpainful dorsiflexion to 10 degrees, as compared to 12 degrees on the left; and by tenderness to palpation of the right Achilles tendon insertion. There was no impairment of function -- the veteran could shop, dance, etc., and had pain only if exertion was high. She walked without a limp, toe and heel walk was normal, there was no palpable defect. Muscle strength was normal -- and the examiner noted that only a mild tendonitis was present and that there was no ankle pathology. These findings are more comparable to the regulatory criteria regarding objective findings for a slight degree of disability and do not approximate the criteria for a moderate degree of disability. 38 C.F.R. § 4.56(d) (1), (2) (1999). Accordingly, the Board concludes that the initial assignment of a noncompensable rating for a slight degree of disability resulting from the service-connected Achilles tendonitis was appropriate. 38 C.F.R. §§ 4.7, 4.56, 4.73, Diagnostic Code 5399-5310 (1999). With regard to a "staged" rating, the evidence dated after the July 1991 VA examination shows moderate swelling in February 1993 following a reinjury to the right ankle at that time. However, the rest of the subsequent evidence shows the right Achilles tendonitis to be manifested solely by complaints of tenderness and examiners commented that the disorder was "healed" or "resolved". Accordingly, the Board concludes that there is no basis on which to assign a "staged" compensable rating. ORDER Service connection for epigastric pain (claimed as a stomach condition) and for a heart condition is denied. The claim for service connection for fibrocystic breast disease, bilateral (claimed as breast condition), is well grounded, and to this extent the appeal is granted. Restoration of service connection for vaginitis is granted. A rating higher than 10 percent for chondromalacia of the left knee is denied. A rating higher than 10 percent for chondromalacia of the right knee is denied. A compensable rating for right Achilles tendonitis is denied. REMAND The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. Fibrocystic Breast Disease, Bilateral (Claimed As Breast Condition). Reason for remand: For the reasons and bases articulated in its decision above, the Board has concluded that the claim for service connection for fibrocystic breast disease, bilateral (claimed as breast condition), is a well grounded claim. 38 U.S.C.A. § 5107(a) (West 1991). However, it is not the type of well grounded claim that is meritorious on its own but rather the type that may be capable of substantiation upon further development of medical evidence. The Board remanded the case in March 1995 for such development, but the evidence obtained did not comply with the remand order. Accordingly, the claim must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). A Rating Higher Than 10 Percent For Vaginitis Reason for remand: The Board notes that the rating criteria for evaluating gynecological conditions were revised in May 1995 during the pendency of the appeal of the initial rating assigned for vaginitis. The veteran had notice of the old criteria in the May 1992 statement of the case and of the new criteria in the February 1999 supplemental statement of the case. Accordingly, the Board concludes that due process requirements have been met with regard to the new rating criteria. VAOPGCPREC 11-97 at 3-4 (Mar. 25, 1997); Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993); Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). However, the Court's decision in Fenderson v. West, as noted above in the Board's discussion of the knee and Achilles tendon claims, contemplates the possibility of "staged" ratings based on facts found in some cases where the veteran appeals the initial disability rating. The evidence most probative to the assignment of an initial rating will be that most contemporaneous with the period during which the veteran claimed service connection for vaginitis (December 1990) and the RO assigned the initial rating upon awarding service connection (September 1991). However, if subsequent evidence shows an increase or decrease in the degree of disability of the condition, a "staged" rating may be assigned. The lengthy appeal process here has extended the period during which such a "staged" rating may be considered from 1990 to the present. The last examination to evaluate the disability from the service-connected vaginitis was in August 1995. Accordingly, the Board concludes that further development is needed. Compensable Ratings For Low Back Pain And For A Panic Disorder. Reason for remand: As noted in the Introduction to this decision above, although a February 1999 supplemental statement of the case provides notice to the veteran that the grant of service connection for the low back pain and panic disorder represents a full resolution of the appeal of the service connection issues -- which is true -- no statement of the case was ever issued following the June 1996 notices of disagreement with the initial noncompensable ratings assigned for the low back pain and panic disorder. Cf. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed.Cir. 1997) (an appeal initiated by a notice of disagreement as to an RO's "rejection of the logically up-stream element of service-connectedness . . . could not concern the logically down-stream element of compensation level."). Accordingly, due process considerations mandate that the case be REMANDED for a statement of the case e on these issues. Manlicon v. West, 12 Vet. App. 238, 240-41 (1999). To ensure that VA has met its duty to assist the claimant in developing the facts pertinent to her claims and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following: 1. The RO should issue a statement of the case in response to the June 1996 notices of disagreement with the noncompensable ratings assigned for the veteran's low back pain and panic disorders and allow her 60 days to perfect her appeal of those issues to the Board if she so desires by filing a VA Form 9 substantive appeal. 38 C.F.R. § 20.302(b) (1999). 2. If and only if the veteran perfects her appeal of any issue noted in #1 above, the RO should obtain all records of treatment pertaining to the disorders on appeal that have not already been associated with the claims file. In addition, the RO should schedule the veteran for VA examinations to assess the current level of disability resulting from the service-connected disorders remaining on appeal. Specifically, the RO should also schedule the veteran for a VA examination to resolve the medical issues involved in her claim for service connection for fibrocystic breast disease (claimed as a breast condition). The examiner must review the medical evidence in the claims file that pertains to a breast disorder and render an opinion on the following matters: (1) Whether fibroadenoma diagnosed in 1970, seventeen years prior to active service, is related to, or the same disease as, the fibrocystic breast disease diagnosed years later and, if so, whether the findings of dense ductile tissue on a mammogram during active duty in 1989 or any other findings on examination of the breasts in service reflect an increase in severity of the preexisting breast disease beyond the normal progress of the disease. (2) Whether the medical findings pertaining to the breasts in service, including the findings on the July 1989 mammogram, represent a separate and distinct disease process from the fibroadenoma of the breasts which preexisted active service. 3. The RO should also obtain all records of the veteran's treatment for vaginitis during the course of the lengthy appeal period that have not already been associated with the claims file. In addition, the RO should schedule the veteran for a VA examination to assess the current level of disability resulting from the service-connected vaginitis. In readjudicating the claim for a rating higher than 10 percent for vaginitis, the RO should consider whether the assignment of "staged" ratings is appropriate based on facts found. 4. Following completion of the above actions, the RO must review the claims folder and ensure that all of the foregoing development is completed. If any development is incomplete, appropriate corrective action is to be implemented. The RO and the appellant are also advised that the Board is obligated by law to ensure that the RO complies with its directives, as well as those of the United States Court of Appeals for Veterans Claims (Court). The Court has stated that compliance by the Board or the RO is neither optional nor discretionary. Where the remand orders of the Board or the Court are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant does not need to take any action unless she is notified. GEORGE R. SENYK Member, Board of Veterans' Appeals