Citation Nr: 0002161 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 95-09 130 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for a chronic sinus disorder with allergies. 2. Entitlement to service connection for the residuals of a right knee injury. 3. Entitlement to service connection for the residuals of a right shoulder injury. 4. Entitlement to service connection for rheumatoid arthritis. 5. Entitlement to an evaluation in excess of 10 percent for the service-connected residuals of a fractured nasal septum with deviation, on appeal from the initial evaluation. REPRESENTATION Appellant represented by: New York Division of Veterans' Affairs ATTORNEY FOR THE BOARD M. A. Herman, Associate Counsel INTRODUCTION The veteran had active military service from May 1979 to April 1983. This appeal arises from a November 1993 rating decision of the Buffalo, New York, regional office (RO) which denied, amongst other issues, service connection for a chronic sinus disorder with allergies, the residuals of a right knee injury, and the residuals of a right shoulder injury, and which assigned a noncompensable evaluation for the residuals of a fractured nasal septum with deviation, after granting service connection for the same. By a rating action dated in August 1995, the noncompensable disability evaluation assigned the residuals of a fractured nasal septum with deviation was increased to 10 percent, effective in November 1992. The November 1993 rating decision also determined that the veteran had failed to submit new and material evidence to reopen the claim of service connection for rheumatoid arthritis. However, in a decision dated in January 1997, the Board of Veteran's Appeals (Board) held that new and material evidence had been submitted to reopen said claim. This matter was Remanded by the Board in January 1997 for the purpose of obtaining additional medical evidence and affording due process to the veteran, and it has been returned to the Board for appellate review. The Board notes that the veteran's representative raised the issue of service connection for a foot rash in October 1999. The RO has yet to consider this issue. Nevertheless, the issue of veteran's entitlement to service connection for a foot rash is not inextricably intertwined with the current appeal, and it is referred to the RO for the appropriate action. FINDINGS OF FACT 1. The veteran has been presently diagnosed as having sinusitis, rhinitis, and chronic right knee and shoulder pain due to rheumatoid arthritis. 2. There is no competent medical evidence linking the veteran's current sinus disorder with allergies, right knee, or right shoulder problems with any incident, accident, or disease that occurred during his military service. 3. The veteran's claim for service connection for chronic sinusitis with allergies is not plausible. 4. The veteran's claim for service connection for the residuals of a right knee injury is not plausible. 5. The veteran's claim for service connection for the residuals of a right shoulder injury is not plausible. 6. A medical examiner opined that there is no evidence that the veteran suffered from arthritis problems or the symptoms of rheumatoid arthritis in service, or that there was evidence confirming a diagnosis of rheumatoid arthritis prior to May 1985. 7. The veteran's fractured nasal septum with deviation was surgically corrected by the septoplasty that was performed in 1993 and he does not currently experience any discernable problems related to said disability. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for chronic sinusitis with allergies is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim of entitlement to service connection for the residuals of a right knee injury is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The claim of entitlement to service connection for the residuals of a right shoulder injury is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. Rheumatoid arthritis was not incurred in military service. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303 (b)(d) (1999). 5. The criteria for rating higher than 10 percent for the residuals of a fractured nasal septum with deviation have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.10, 4.97, Diagnostic Code 6502 (1996 & 1999) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran's enlistment examination indicated that his nose, sinuses, upper extremities, and lower extremities were normal. In September 1980, he was assaulted by four individuals. He stated he had been kicked in the nose, and that he had fallen upon his left wrist. There was a contusion to the orbit of the right eye. An x-ray of his nose revealed a fracture to the septum with minor deviation. He denied having any problems breathing. There was mild swelling of the left wrist. The assessment was hematoma of the right eye and sprain of the left wrist. In January 1983, the veteran was evaluated for complaints of left thigh pain. He denied any trauma. There was palpable tenderness to the left inner thigh near the scrotum and along the inguinal ligament. There was no evidence of hernia. The assessment was left inguinal ligament strain. On a Report of Physical Examination pending service discharge, the veteran's nose, sinuses, upper extremities, and lower extremities were found to be normal. Service medical records show that he was treated for complaints of a sore throat in October 1980 and April 1981, and that he was diagnosed as having upper respiratory infections and a strep throat. There were no findings pertaining to a chronic sinus or allergy problem. The veteran filed a claim for service connection for rheumatoid arthritis in February 1987. He indicated he had received post-service treatment for arthritis and/or joint pain through Drs. Zoghlin, Piccoli, and Atwater. Medical records from E.C. Atwater, M.D., dated from April 1986 to February 1987 document that the veteran received evaluations and treatment for rheumatoid arthritis. He was noted to have rheumatoid nodules on his thumbs, fingers, Achilles tendon, and both elbows. The etiology of the rheumatoid arthritis was not discussed. The office of L.N. Zoghlin, M.D., reported in March 1987 that it did not have any records pertaining to the treatment of the veteran. Various medical and billing records were forwarded from the New York State Department of Social Services. These records were culled by the Office of Disability Determination in the course of reviewing the veteran's claim for disability benefits. Significantly, a medical bill from ACM Medical Laboratory revealed that the veteran had an A-82 Profile and Sed. Rate performed at the request of Dr. Zoghlin in June 1983. There was an April 1985 note from the office of Dr. Zoghlin that indicated that the veteran had been diagnosed as having fibromyositis. However, there was an April 1985 billing record from Dr. Zoghlin showing the veteran had a diagnosis of arthritis. The veteran was afforded a VA general medical examination in April 1987. He maintained that he experienced stiffness of the knees during his active military service, and that he sought treatment for the same almost immediately after his service discharge. He stated he was initially diagnosed as having fibromyositis. He reported having rheumatoid arthritis nodules removed from his left elbow. He indicated he had experienced good results with gold therapy. The veteran's hands were puffy but without deformity. He had subcutaneous nodules along the olecranon process of the right elbow. Nodules were also identified in both Achilles tendons and the metatarsal phalangeal joints of both great toes. A serology was negative for rheumatoid arthritis. The diagnosis was rheumatoid arthritis in remission following gold therapy. The examination report contained no findings pertaining to the veteran's nose, sinuses, mouth, or throat. Service connection for rheumatoid arthritis was denied in August 1987. The RO found the evidence of record failed to establish that rheumatoid arthritis was incurred in or aggravated by the veteran's military service. The RO also determined there was no evidence that the veteran had been diagnosed as having rheumatoid arthritis within one-year of his service discharge. In a letter dated in August 1987, Dr. Zoghlin reported that he had been concerned that the veteran had rheumatoid arthritis symptoms as early as July 1978. He said the veteran had a negative antinuclear antibody at that time. He recalled that the veteran's last treatment had been in June 1985, and that he had been seen on several occasions starting in June 1983. By a rating action dated in September 1987, service connection for rheumatoid arthritis was denied. The RO determined that the letter from Dr. Zoghlin failed to establish the veteran's current rheumatoid arthritis had its onset in service or within the one-year post-discharge presumptive period. Treatment notes from Dr. Zoghlin showed that the veteran was seen for complaints of right shoulder pain in June 1983. He denied injury. He was noted to have had a three-(3) week history of polyarthritis that had been worse in the shoulders. He was referred for a battery of diagnostic tests to include an arthritis profile. A follow-up report dated in July 1983 indicated that the veteran's complaints of "polyarthritis" of the joints were completely remissed. He did, however, continue to complain of a "little pain" in his right thigh. The veteran was next seen for complaints of joint pain (left shoulder) in April 1985. In November 1992, the veteran filed a claim for service connection for multiple conditions including the residuals of a fractured nose, sinus and allergy problems, arthritis of multiple joints, the residuals of a right knee injury, and the residuals of a right shoulder injury. Treatment records from E.C. Atwater, M.D., dated from September 1985 to September 1986 show that the veteran received evaluations and treatment for rheumatoid arthritis. A September 1985 examination report indicated that he had been referred to Dr. Atwater by Dr. Amo Piccoli (the veteran's personal physician), and that he had been treated and cared for previously by Dr. Zoghlin. He said he had been experiencing aching in his joints since 1977. Based on the history and a physical examination, the impression was that the veteran had rheumatoid arthritis. This diagnosis was later confirmed following the reciept of laboratory test results. Medical records from the Syracuse VA Medical Center (VAMC) dated from April 1987 to September 1992 show that the veteran received evaluations and treatment for, but not limited to, sinusitis and rheumatoid arthritis. Significantly, he was seen in April 1987 for complaints of nasal congestion. He said he had been experiencing congestion for the past week. There was nasal congestion bilaterally. The diagnosis was rhinitis with pharyngitis. Similar findings were made in November 1987 and March 1989. A May 1989 consultation report indicated that he was seen for complaints of sinusitis with purulent discharge. The aforementioned records also contained several references to the veteran complaining of joint pain to include the right shoulder and knee. In each instance, the complaints of right shoulder and knee pain were attributed to exacerbations of his rheumatoid arthritis. There were no findings with regard to the etiology of the veteran's rheumatoid arthritis, sinusitis, or rhinitis. A letter from Dr. Zoghlin was received in June 1993. Dr. Zoghlin reported that the veteran's medical records had been sent to the Shortsville Family Practice in December 1984. He said he saw the veteran on one other occasion in August 1987, At that time, Dr. Zoghlin said that he suspected, but could not prove, that the veteran suffered from rheumatoid arthritis. In November 1993, service connection for the residuals of a fractured nasal septum with deviation was granted and a noncompensable disability evaluation was assigned. The claims of service connection for a chronic sinus disorder with allergies, the residuals of a right knee injury, the residuals of a right shoulder injury were denied. The RO also determined that the veteran had failed to submit new and material evidence to reopen the claim of service connection for rheumatoid arthritis. Medical records from the Syracuse VAMC dated from September 1993 to August 1994 were associated with the claims folder. The veteran was admitted in September 1993 due to complaints of long history of difficulty breathing through his nose and obnoxious snoring that interfered with his sleep. He indicated that he had had increased difficulty since being assaulted and suffering nasal trauma six (6) years earlier. On physical examination, the veteran's nose was thickened with displaced septal cartilage to the right. There was a lumen on the right anteriorly and a narrow posterior lumen on the left. There was a spur inferiorly on the right septum. The oropharynx was otherwise benign. The veteran had a pendulous uvula and redundant mucosal folds posteriorly along the soft palate. It was believed that he suffered from sleep apnea. He underwent first stage septoplasty that same month. An August 1994 follow up report indicated that the veteran continued to experience nasal congestion and snoring. There was nasal septal deviation to the right with some dryness/crusting. There was also some irritation of the oropharynx. Lesions were observed on the left. There was some redundancy of the soft palate. The assessment was nasal septal deviation causing obstruction with possible obstructive sleep apnea. The veteran filed a substantive appeal in March 1995. He asserted that his service-connected nasal fracture warranted a 10 percent disability rating because he experienced a marked interference with breathing space. He maintained his sinus and allergy problems first manifested in service, and that he had continued to suffer from the same since that time. Similarly, he stated his service medical records showed that he injured his right knee and right shoulder during his active military service. The veteran further argued that the evidence showing treatment for arthritis in the early 1980s was new and material evidence. By a rating action dated in August 1995, the noncompensable assigned to the residuals of a fractured nasal septum with deviation was increased to 10 percent. The effective date of the award was November 1992. The RO indicated that this was the maximum benefit available to the veteran. In January 1997, the Board determined that the veteran had submitted new and material evidence to reopen the claim of service connection for rheumatoid arthritis. The issue of service connection for rheumatoid arthritis was therefore remanded for the purpose of affording due process to the veteran. The Board also indicated that additional medical evidence needed to be obtained prior to final appellate consideration of the issue. The issues of service connection for a chronic sinus disorder with allergies, the residuals of a right knee injury, and the residuals of a right shoulder injury were remanded in order to secure VA and non-VA treatment records that the RO may not have previously gathered. Further, the issue of the veteran's entitlement to an evaluation in excess of 10 percent for the service- connected residuals of a fractured nasal septum with deviation was returned to the RO for the purpose of affording the veteran a VA otolaryngology examination to determine the severity of said disability. Medical records from the Syracuse VAMC dated from May 1992 to January 1997 show that the veteran received treatment for rheumatoid arthritis, multiple joint pain, and nasal problems. His complaints pertaining to pain of the shoulders and knees were attributed to rheumatoid arthritis. There were no findings that related his rheumatoid arthritis or right shoulder and right knee pain to any incident arising during his military service. Following his septoplasty in September 1993, outpatient records show that the veteran continued to complain of snoring and nasal obstruction. As there was a question as to whether he suffered from obstructive sleep apnea, he was afforded a daytime polysomonography screening in October 1994. This study showed about one-and-a-quarter hours of sleep with normal sleep stage durations. No sleep apneas were noted. The study was negative for sleep apneas. In March 1995, the veteran was seen for complaints of obnoxious snoring. He maintained that the previous sleep study had been poor. He said his wife had observed his apnea. He indicated that he had a smoking habit of three- quarters of pack per day. An examination showed that the septum of his nose was straight. His tonsils were plus two and plus three. There was narrowing of the oropharynx. The uvula was thickened. The assessment was obnoxious snoring and possible mild obstructive sleep apnea. That same month, the veteran underwent a tonsillectomy and a uvulopalatopharyngoplasty. A letter sent to Dr. Piccoli requesting that he forward the veteran's medical records was returned to the RO in July 1997. The post office indicated that the letter was undeliverable. Records from the University of Rochester Medical Center dated from June 1986 to January 1987 document the evaluation and treatment of rheumatoid nodules that had developed on the extensor surface of the proximal forearm. The veteran underwent a surgical removal of said nodules in August 1986. While references were made to the veteran having a history of arthritis pain for several years, the date of onset of his rheumatoid arthritis was not discussed by the treating physicians, Drs. Miller and Jimenez. Treatment records dated between November 1983 and October 1986 were received from the medical department of the Eastman Kodak Company. The veteran was first seen for complaints of left shoulder pain in April 1985. He said he had a long-term problem with stiffness and achiness in his shoulders and knees. He stated he had seen Dr. Zoghlin in 1983, and that he was told to take aspirin. The veteran was seen routinely for complaints of multiple joint pain for the remainder of the year and various diagnoses were considered to include possible arthritis, possible biceps tendonitis, possible rotator cuff problem, and fibromyositis. However, a September 1985 treatment note indicated that a diagnosis of rheumatoid arthritis had been rendered by Dr. Atwater that same month. Subsequent entries showed that the veteran received routine treatment for rheumatoid arthritis that included gold shots. The etiology of the condition was not discussed. In July 1997, the office of Dr. Zoghlin reported that it could not identify the veteran as having been a patient at their facility. The RO informed the veteran of this development in an August 1997 letter. He was also advised that Dr. Atwater had not responded to its request for his medical records, and that the request of records sent to Dr. Piccoli had been returned as undeliverable. The RO asked that the veteran assist it in obtaining these records. The veteran submitted an undated letter from Dr. Piccoli in September 1997. Therein, Dr. Piccoli informed the veteran that he was retiring as of April 30, 1987. He said that Dr. Carlos Jimnez-Rueda would be taking over the practice and had agreed to hold all medical records in the office. In an attached statement, the veteran indicated that his records from Dr. Piccoli were being held at the Shortsville Family Practice. He submitted a release form for those records. In December 1997, the Shortsville Family Practice reported that it had held no records pertaining to the veteran. Additional treatment records from the Eastman Kodak Company dated from November 1985 to February 1989 were associated with the claims folder. Of note, a physician's report, prepared as part of a long-term disability claim, indicated that the onset of the veteran migratory polyarthritis dated back to May 1985. The examiner stated that a laboratory examination conducted at that time had led to the diagnostic impression that the veteran had "early stage rheumatoid arthritis." The examiner said that the veteran's illness was followed by the medical department, in consultation with his rheumatologist, Dr. Atwater, until his last day of work. Similar findings were made by the corporate rehabilitation consultant in April 1988. In November 1998, the RO indicated that it had requested the veteran's medical records from the Rochester VA outpatient treatment center. However, it was noted that those were no longer available at said facility, and that the records were being held by the Canandaigua VAMC. The Canandaigua VAMC subsequently reported in May 1999 that it held no information pertaining to the veteran. In July 1999, the veteran was afforded a VA otolaryngology examination. He discussed his inservice nose injury, the problems he experienced thereafter, and his 1994 septoplasty. He stated he had no problems since the operation. However, he did complain of occasional nasal dyspnea that seemed to change from side to side every couple of hours. He denied having any current sinus pain or pressure. He said he periodically experienced rhinorrhea. On examination, the veteran's voice was neither hypo nor hyper nasal. There was a very slight external deviation of the nose to the left. This was mainly the upper lateral cartilages. Intranasal examination revealed a well-healed, right-sided heavy transfixation scar. His septum was visibly and palpably midline. Anterior rhinoscopy failed to reveal any other pathology. There was no significant turbinate hypertrophy or polypoid disease identified. The assessment was that the veteran's deviated septum did contribute to nasal dyspnea prior to his surgery. His current complaints appeared to be normal physiologic alternating nasal dyspnea associated with the normal cycle of air warming during respiration. The examiner stated that the physical examination did not reveal any persistent nasal deformity that would contribute to nasal dyspnea. The examiner opined that the veteran breathed nicely through his nose. It was the judgment of the examiner that the veteran's problem had resolved and was surgically corrected by the septoplasty performed in 1993. The veteran was also afforded a VA orthopedic examination in July 1999. He stated that his symptoms of stiffness in the shoulders and knees began during his active military service. However, he could not recall whether he ever received an inservice evaluation for these complaints. The examiner expressed some confusion as to why an orthopedic examiner had been asked to render an opinion regarding rheumatoid arthritis. Nevertheless, after conducting a limited physical examination and reviewing the claims folder, the examiner found there was no specific evidence that the veteran was evaluated for arthritis problems or symptoms of rheumatoid arthritis while he was in service. The fact that rheumatoid arthritis was diagnosed later in May 1985 was clear. The examiner opined that it was very likely that the rheumatoid arthritis predated that specific date. However, the examiner stated that it was not possible to give the likely onset of rheumatoid arthritis. In October 1999, service connection for a chronic sinus disorder with allergies, the residuals of a right knee injury, the residuals of a right shoulder injury, and rheumatoid arthritis was denied. The RO found the evidence failed to establish an etiological relationship between any current disability of the sinuses, right shoulder, or right knee and the veteran's military service. Similarly, the RO held there was no evidence demonstrating that the veteran's rheumatoid arthritis had its onset in service or within the one-year post-service presumptive period. The claim for an increased evaluation for the service-connected residuals of a fractured nasal septum with deviation was also denied. A supplemental statement of the case (SSOC) was mailed to the veteran that same month. The SSOC included a citation to the old and revised criteria used in evaluating deviation of the nasal septum. II. Analysis A. Service Connection Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated by service. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303(a) (1999). Where a veteran served 90 days or more during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. § 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. § 3.307, 3.309 (1999). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). A person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. The Secretary shall assist such a claimant in developing the facts pertinent to the claim. 38 U.S.C.A. § 5107(a). Thus, the threshold question to be addressed in this case is whether the veteran has presented evidence of a well-grounded claim. If the veteran has not presented a well-grounded claim, the appeal must fail because the Board has no jurisdiction to adjudicate the claim. Boeck v. Brown, 6 Vet. App. 14, 17 (1993). In Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that, under 38 U.S.C.A. § 5107(a), the Department of Veterans Affairs (VA) has a duty to assist only those claimants who have established well grounded (i.e., plausible) claims. More recently, the U.S. Court of Appeals for Veterans Claims (Court) issued a decision holding that VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). Because a well-grounded claim is neither defined by the statute nor the legislative history, it must be given a commonsense construction. A well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of 38 U.S.C.A. § 5107(a). Id. at 81. However, to be well grounded, a claim must be accompanied by evidence that suggests more than a purely speculative basis for granting entitlement to the requested benefits. Dixon v. Derwinski, 3 Vet. App. 261, 262-263 (1992). The Court has held that evidentiary assertions accompanying a claim for VA benefits must be accepted as true for purposes of determining whether the claim is well grounded. Exceptions to this rule occur when the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is plausible or possible is required. Murphy, 1 Vet. App. at 81. A claimant would not meet this burden merely by presenting lay testimony, because lay persons are not competent to offer medical opinions. Espiritu, 2 Vet. App. at 495. A claim for service connection requires three elements to be well grounded. There must be competent evidence of a current disability (a medical diagnosis); incurrence or aggravation of a disease or injury in service (lay or medical evidence); and a nexus between the in-service injury or disease and the current disability (medical evidence). The third element may be established by the use of statutory presumptions. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). In the alternative, the chronicity provisions of 38 C.F.R. § 3.303(b) are applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumptive period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which under case law of the Court, lay observation is competent. If chronicity is not applicable, a claim may still be well grounded on the basis of 38 C.F.R. §3.303(b) if the condition is noted during service or during an applicable presumptive period, and if competent evidence, either medical or lay, depending on the circumstances, relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). 1. Sinusitis with Allergies, Residuals of Right Knee Injury, and Residuals of Right Shoulder Injury Here, there is no medical evidence to establish a causal link between the veteran's current sinusitis with allergies and military service. The veteran has not offered any medical opinion that attributes his diagnosed sinusitis or rhinitis to his military service. Similarly, evidence showing a correlation between the veteran's current complaints of chronic right knee and shoulder pain and his military service has not been submitted. The veteran's opinion that there is an etiological relationship between his military service and his current diagnosis of these conditions does not meet this standard. Questions of medical diagnosis or causation require the expertise of a medical professional. See Espiritu. There is no evidence that the veteran has the medical background sufficient to render such an opinion. In fact, the medical evidence of record seems to clearly show that the veteran's complaints of right knee and shoulder pain are a manifestation of his rheumatoid arthritis rather than a separate disease process or injury. Moreover, service medical records are devoid of any evidence showing treatment for a chronic sinus, right knee, or right elbow condition. His service discharge examination indicated that his sinuses, upper extremities, and lower extremities were normal. In other words, the presence of a chronic disability of the sinuses, right knee, or right shoulder during active service is not shown. Despite the foregoing, as previously referenced, a claimant may still obtain the benefit of § 3.303(b) by providing evidence of continuity of symptomatology. Evidence of continuity is determined by symptoms not treatment. However, in determining the merits of a claim, the lack of evidence of treatment may bear on the credibility of the evidence of continuity. Equally important, since a lay person is not competent to render an opinion pertaining to the diagnosis of sinusitis and a disability of the knee or shoulder, medical evidence is required to demonstrate a relationship between these disorders and any symptoms experienced post-service. See Grottveit v. Brown, 5 Vet. App. 91 (1993); Layno v. Brown, 6 Vet. App. 465 (1994). No such medical evidence has been submitted in this case. Based on the above, the Board concludes that the veteran has not submitted well-grounded claims, and his claims for service connection for chronic sinusitis, the residuals of a right knee injury, and the residuals of a right shoulder injury must be denied. 2. Rheumatoid Arthritis The veteran has satisfied the threshold requirement of presenting a well-grounded claim within the meaning of 38 U.S.C.A. § 5107(a). The veteran claims that he experienced multiple joint pain in service. The veteran has also provided evidence showing that he continued to suffer from multiple joint pain shortly after his service discharge, and that those complaints could have been manifestations of arthritis. Therefore, the Board finds that the veteran has submitted sufficient medical evidence appearing to suggest a diagnosis of "polyarthritis" within one year of service discharge to make his claim plausible. See 38 C.F.R. §§ 3.307, 3.309. The Board is also satisfied that all relevant facts have been properly developed and that no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). On evidentiary evaluation, the Board observes that it must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Eddy v. Brown, 9 Vet. App. 52 (1996). In the present case, the Board finds that the evidence of record shows that the veteran was not diagnosed as having rheumatoid arthritis until 1985. Records predating the 1985 diagnosis show that the veteran's complaint of left shoulder pain was variously diagnosed as being possible arthritis, possible biceps tendonitis, possible rotator cuff problem, and fibromyositis. Based on a review of this medical history, a VA physician opined in July 1999 that there was no specific evidence that the veteran was evaluated for arthritis problems or symptoms of rheumatoid arthritis while he was in service. The examiner further concluded that evidence documenting the onset of rheumatoid arthritis prior to May 1985 had not been submitted. The Board finds that this medical report constitutes significantly probative evidence due to the fact that it entailed a comprehensive review of the veteran's medical history by a medical professional. By contrast, post-service treatment records hinting at a similarity between his complaints of left shoulder pain in 1983 and the diagnosis of rheumatoid arthritis in 1985 have greatly diminished probative value because they do not appear to be supported by any objective and credible medical authority. There were no actual findings that related the veteran's current rheumatoid arthritis to the symptoms he allegedly experienced in service or in 1983. While the evidence showing post-service "polyarthritic" symptoms was sufficient to make his claim well grounded, the same evidence is insufficient when weighed against the evidence of record and the opinion rendered by the VA examiner. In sum, the Board finds that the July 1999 VA examination report clearly outweighs the post-service treatment records that were submitted by the veteran. As a relative balance of positive and negative evidence has not been presented, the doctrine of benefit of the doubt is not for application. Accordingly, the claim for service connection for rheumatoid arthritis is simply not established by the evidence of record. B. Increased Evaluation The Board initially finds that the veteran has submitted a well-grounded, or plausible, claim. 38 U.S.C.A. § 5107(a) (West 1991). When a claimant is awarded service connection for a disability and subsequently appeals the RO's assignment of a rating for that disability, the claim continues to be well-grounded as long as the rating schedule provides for a higher rating and the claim remains open. See Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). The Board is also satisfied that all relevant facts have been properly developed. A VA examination has been performed. The Board finds the examination was adequate concerning the issue at hand, and that there is no indication that there are relevant post-service medical records available that would support the veteran's claim. Therefore, no further assistance to the veteran is required in order to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. These requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based on a single, incomplete or inaccurate report and to enable the VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Moreover, the VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. The provisions of 38 C.F.R. § 4.10 indicate that the basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Whatever system is affected, evaluations are based upon lack of usefulness of these parts or systems, especially in self-support. The medical examiner must therefore furnish, in addition to the etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, a full description of the effects of disability upon the person's ordinary activity. On October 7, 1996, during the pendency of the veteran's appeal, the regulations governing the evaluation of diseases of the nose and throat, which include a deviated nasal septum, were amended. The RO has considered the claim under both the former and revised criteria and determined that a higher rating is not warranted under either. See Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991) (where the governing laws or regulations change after a claim has been filed, but before the appeal is decided, the version most favorable to the veteran must be applied, absent a contrary intent of Congress or the Secretary of VA). The RO also furnished the veteran a supplemental statement of the case in October 1999, containing both the former and revised criteria, and an explanation for the decision, and gave him an opportunity to submit written or other argument in response. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Thus, there is no prejudice to the veteran in the Board evaluating his disability under both the former and revised criteria, and applying the more favorable result. According to the criteria that were in effect prior to October 7, 1996, a 10 percent rating was warranted for a deviated nasal septum if there was evidence of marked interference with breathing space. 38 C.F.R. § 4.97, Diagnostic Code 6502 (1996). This was the maximum rating that could be assigned under this Code. On the other hand, under the revised criteria, , a 10 percent rating is warranted if there is evidence of 50-percent obstruction of the nasal passage on both sides, or complete obstruction on one side. 38 C.F.R. § 4.97, Diagnostic Code 6502 (1999). This continues to be the maximum rating that can be assigned under this Code. On examination in July 1999, the veteran was noted to have a very slight external deviation of the nose to the left. His septum was visibly and palpably midline. Anterior rhinoscopy failed to reveal any other pathology. There was no significant turbinate hypertrophy or polypoid disease identified. The assessment was that the veteran's deviated septum did contribute to nasal dyspnea prior to his 1993 surgery. The examiner stated that the physical examination did not reveal any persistent nasal deformity that would contribute to nasal dyspnea. Observing that the veteran breathed nicely through his nose, the opinion was that the veteran's problem had resolved and, in fact, been corrected by a septoplasty that been performed in 1993. The Board finds that the above referenced medical evidence reveals that the veteran's fractured nasal septum with deviation is essentially asymptomatic. Moreover, as referenced above, the maximum disability rating assignable for deviation of the nasal septum is 10 percent. Given these conclusions, the Board holds that a disability evaluation in excess of the 10 percent currently assigned to the residuals of a fractured nasal septum with deviation would be inappropriate under either the former or revised criteria. In so deciding, consideration has been given to assigning staged ratings; however, at no time during the period in question has the veteran shown disablement equivalent to that greater than the assigned rating. Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered the assignment of a higher evaluation in this case on an extra-schedular basis under 38 C.F.R. § 3.321(b)(1). A basis for an extra-schedular evaluation is not shown, however, as the service-connected residuals of a fractured nasal septum with deviation does not result in marked interference with employment or frequent periods of hospitalization, or otherwise present an exceptional or unusual disability picture. For all the foregoing reasons, the Board concludes that, as the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and a rating higher than 10 percent for the residuals of a fractured nasal septum with deviation is not warranted. ORDER Entitlement to service connection for a chronic sinus disorder with allergies is denied. Entitlement to service connection for the residuals of a right knee injury is denied. Entitlement to service connection for the residuals of a right shoulder injury is denied. Entitlement to service connection for rheumatoid arthritis is denied. Entitlement to an evaluation in excess of 10 percent for the service-connected residuals of a fractured nasal septum with deviation, on appeal from the initial evaluation, is denied. G. JIVENS-MCRAE Acting Member, Board of Veterans' Appeals