BVA9507600 DOCKET NO. 90-45 400 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Medical and Regional Office Center in Togus, Maine THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a left shoulder disorder. 2. Entitlement to service connection for a right knee disorder. 3. Entitlement to service connection for a neck disorder. 4. Entitlement to service connection for a bladder disorder, claimed as secondary to medication received for service-connected disabilities. 5. Entitlement to a total rating based on unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD William W. Berg, Counsel INTRODUCTION The veteran had active military service from January 1943 to December 1945. He was a prisoner of war of the German government from December 1944 to May 1945. When this case was previously before the Board of Veterans' Appeals (Board) in September 1992, it was remanded to the Department of Veterans Affairs (VA) Medical and Regional Office Center (M&ROC, hereinafter RO) in Togus, Maine, for additional development. The case is now before the Board for final appellate consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran and his representative contend, in essence, that he is entitled to service connection for a left shoulder disorder, a right knee disorder and a neck disorder because these disorders resulted from injuries sustained during combat shortly before being taken a prisoner of war. He also claims that he acquired his disabilities as a result of mistreatment during his internment as a prisoner of war. It is also maintained that he has a bladder disorder as a result of medications received for his service-connected disabilities. The veteran maintains that treatment with various medications over many years for his service-connected disorders has caused his current bladder disorder. It is also maintained by and on behalf of the veteran that he is entitled to a total rating based on unemployability due to service-connected disabilities (total compensation rating) because he has been unable to work as a consequence of his service-connected disorders since the early 1980's. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claims for service connection for a left shoulder disorder; a right knee disorder; and a neck disorder, including degenerative joint disease of the cervical spine. It is the further decision of the Board that the veteran has not met the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that his claim for service connection for a bladder disorder, claimed as secondary to medication received for service-connected disabilities, is well grounded. It is also the decision of the Board that the evidence warrants a total compensation rating. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal has been obtained. 2. Entitlement to service connection for a left shoulder disorder was denied by the RO in an unappealed rating decision dated in March 1986. 3. Evidence added to the record since the March 1986 rating decision, when viewed in conjunction with the evidence previously of record, while new, is not sufficient to raise a reasonable possibility of an outcome different from that reached by the RO in 1986. 4. A right knee disorder was not present in service or until many years thereafter and is not shown to be related to service. 5. A neck disorder, including degenerative joint disease of the cervical spine, was not present in service or until many years thereafter and is not shown to be related to service; degenerative joint disease of the cervical spine is not shown to be of traumatic etiology. 6. Service connection is in effect for a generalized anxiety disorder with conversion symptoms, depressed features, somatization and post-traumatic stress disorder, evaluated as 50 percent disabling; postoperative residuals of a vagotomy and pyloroplasty for a gastric ulcer, evaluated as 20 percent disabling; and arthritis of the left knee due to trauma as a prisoner of war, evaluated as 10 percent disabling. 7. A combined service-connected evaluation of 60 percent has been in effect since August 1987. 8. The claim for service connection for a bladder disorder, claimed as secondary to medication received for service-connected disabilities, is not plausible. 9. The veteran has no more than a seventh grade education and work experience as a laborer in a potato shipping plant, lumberjack, farm hand, truck driver, butcher, school bus driver, and as a laborer, machine operator, section foreman and trackman for a railroad; he last worked in the early 1980's. 10. The veteran's service-connected disabilities are sufficiently disabling to preclude him from securing or following any form of substantially gainful employment consistent with his education and work experience. CONCLUSIONS OF LAW 1. Evidence received since the March 1986 rating decision denying service connection for a left shoulder disorder is not new and material, and the claim for this benefit is not reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1994). 2. A right knee disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1994). 3. A neck disorder was not incurred in or aggravated by service, nor may degenerative joint disease of the cervical spine be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991); 38 C.F.R. § 3.303, 3.307, 3.309 (1994). 4. The claim for service connection for a bladder disorder, claimed as secondary to medication received for service-connected disabilities, is not well grounded. 38 U.S.C.A. § 5107 (West 1991). 5. The criteria for a total compensation rating have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 3.340, 3.341, 3.400, 4.16 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a preliminary matter, the Board notes that the veteran's decorations include the Combat Infantryman Badge and that he was a prisoner of war of the German government from December 1944 to May 1945. In view of the provisions of 38 U.S.C.A. §§ 1112(b) and 1154(b) (West 1991), the Board finds that the veteran's claims for service connection for right knee and neck disorders are plausible and thus well grounded within the meaning of 38 U.S.C.A. § 5107(a). The Board further finds that his claim for a total compensation rating is also well grounded under 38 U.S.C.A. § 5107(a), as it is in the nature of a claim for an increased evaluation. See Proscelle v. Derwinski, 2 Vet.App. 629 (1992) (a claim of entitlement to an increased evaluation for a service- connected disability generally is a well-grounded claim). The Board is also satisfied that all relevant evidence has been obtained with respect to these claims and that no further assistance to the veteran is required in order to comply with the duty to assist mandated by statute. I. Service Connection for Left Shoulder, Right Knee and Neck Disorders A. Left Shoulder Disorder The veteran's claim for service connection for a left shoulder disorder was denied by the RO in March 1986, and he was given written notification of that determination. A timely appeal was not thereafter received. Accordingly, the rating decision became final. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. §§ 3.104(a), 20.302 (1994). However, the claim will be reopened if new and material evidence has been submitted. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a); Manio v. Derwinski, 1 Vet.App. 140, 145 (1991). Evidence that was of record at the time of the prior unappealed rating decision included the veteran's service medical and personnel records and numerous reports of VA and private examination and treatment over the years since the conclusion of his World War II service. His service medical records are negative for complaints or findings of a left shoulder disorder, including any complaint of a left shoulder dislocation sustained just before being taken a prisoner of war. Despite the numerous medical reports of record at the time of the March 1986 rating decision, the earliest complaints of a left shoulder disability were noted on a Prisoner-of-War Protocol Examination conducted by VA in January 1986. On a social work survey performed in conjunction with that examination, the veteran claimed that he had injured his shoulder diving into a foxhole shortly before capture by the Germans. X-rays of the left shoulder showed marginal degenerative changes and elevation of the humeral head suggestive of a rotator cuff injury, but the veteran was found to be a very poor historian and to be vague concerning the symptoms of his claimed disorders. The pertinent diagnosis was possible rotator cuff tear of the left shoulder. Evidence received since the March 1986 rating decision includes extensive private and VA medical reports and a report of VA field examination. Statements and hearing testimony by the veteran attributing his left shoulder disability to service were also received. "New" evidence is evidence that is not merely cumulative of evidence previously of record. Colvin v. Derwinski, 1 Vet.App. 171, 174 (1991). "Material" evidence is evidence that is relevant to, and probative of the issue at hand and which is of sufficient weight that there is a reasonable possibility that the new evidence, when viewed in the context of all the evidence of record, both new and old, would result in a different outcome. Cox v. Brown, 5 Vet.App. 95, 98 (1993). In determining whether to reopen a previously denied claim, the new evidence is presumed to be credible. Justus v. Principi, 3 Vet.App. 510, 513 (1992). The Board finds that while the evidence added to the record since the prior unappealed rating decision is new because it is not wholly cumulative, it is not material. When the veteran underwent orthopedic examination by VA in August 1993, X-rays of the left shoulder were interpreted by the examiner as being within normal limits, and the diagnoses included adhesive capsulitis of both shoulders. The presence of arthritis of the left shoulder was thus not confirmed, and the issue of whether the veteran has post-traumatic arthritis of the shoulder for purposes of entitlement to service connection on a presumptive basis under 38 U.S.C.A. § 1112(b) is moot. Moreover, there is substantial reason to doubt that any current left shoulder disorder resulted from service. Not only is the record silent for complaints referable to the left shoulder for more than 40 years following service, the veteran himself has not been consistent in describing how he acquired his left shoulder disorder. When the veteran testified at the RO in July 1990, he indicated that he was running in a cabbage field and tripped, falling and injuring his left shoulder. He reported that the Germans pulled him into a pillbox, and put his left arm in a sling. He also testified that while a prisoner-of-war he was frequently beaten by camp guards about the head and shoulders with a club or rifle butt. Yet when examined by VA in January 1990, he said that he injured his left shoulder when he threw himself to the ground during an artillery barrage. The veteran indicated on a VA social work survey in 1986 that he injured his left shoulder diving into a foxhole. The veteran has also claimed on a number of occasions over the years that he sustained injuries in, and was captured during the Battle of the Bulge. However, his service records do not show that he participated in the Ardennes (Battle of the Bulge) campaign; rather, they show that he became a prisoner of war nearly two weeks before that battle began. It is significant that after service until the early 1980's, he worked in laboring jobs that appear to have been physically taxing and that his complaints of left shoulder disability did not arise until about 1986. Dr. Johnson indicated in a letter dated in March 1984 that he had treated the veteran for about 20 years for a variety of complaints, but he made no mention of any left shoulder complaints. A VA examination in January 1990 indicated that the veteran had a probable old left shoulder separation with chronic left shoulder girdle strain secondary to trauma in service, but X-ray studies showed no evidence of arthritis. Although the examiner appeared to attribute the veteran's left shoulder disorder to trauma in service, his opinion was based entirely on a history related by the veteran and can be no better than the facts alleged by him. Elkins v. Brown, 5 Vet.App. 474, 478 (1993); Reonal v. Brown, 5 Vet.App. 458, 460-61 (1993); Swann v. Brown, 5 Vet.App. 229, 233 (1993). A rejection of the factual predicate necessarily involves a rejection of the etiological opinion based on that predicate. It is notable that the VA orthopedic examiner in August 1993 specifically found that the veteran's left shoulder symptoms could not be directly related to his service many years previously and that when the veteran was again examined by VA in August 1994, the left shoulder was not even mentioned. In these circumstances, the Board finds that the additional evidence lacks sufficient weight, when viewed in conjunction with the evidence previously of record, to result in an outcome different from that reached by the RO in March 1986. Cox v. Brown, 5 Vet.App. at 98. The new evidence is therefore not material. As evidence that is both new and material has not been received, the application to reopen the claim for service connection for a left shoulder disorder must be denied. B. Right Knee Disorder The service medical records are completely negative for complaints or findings referable to right knee disability, and the post service medical evidence is similarly negative for right knee pathology until many years following separation, despite the fact that the veteran was hospitalized at a VA facility in December 1952 after falling and striking both knees on the pavement a couple of days prior to admission. Although a fracture of the left patella was found, a physical examination was otherwise unremarkable when the veteran was admitted to the hospital. The earliest indication in the record of right knee problems is not until September 1975, when the veteran was admitted to a private hospital for treatment of an unrelated disability. It was then reported that the veteran had experienced trouble with his right knee about four years previously, although the nature of that trouble was not specified. His extremities showed no swelling on examination and were felt to be "okay". A right knee disorder was not diagnosed. When examined on admission to a VA hospital in September 1981, however, multiple scars on both legs "from old injuries" were noted. The veteran gave a history of a shrapnel wound of the left leg during service, but a right knee disorder is not shown. In a letter dated in January 1982, Dr. Johnson, the veteran's private treating physician, noted the veteran's many complaints, including his complaints of "rheumatism all over." He reported that the veteran had good range of motion of his knees and that his extremities were unremarkable. The diagnoses included chronic conversion symptoms with somatization. This diagnosis was subsequently confirmed on a number of VA psychiatric evaluations. Thus, in the years following Dr. Johnson's evaluation, the veteran complained intermittently of vague symptoms associated with the right knee, although a true organic basis for these complaints is not shown until 1990. On the Prisoner-of-War Protocol Examination conducted by VA in January 1986, the veteran complained of joint pain in the knees and occasional joint swelling. However, the range of motion of his right knee was normal on clinical examination, and a right knee disability was not found. Dr. Cyr in a letter dated in August 1988 notes that he had treated the veteran since the previous October for a variety of complaints, including a shrapnel wound of the left knee, but right knee disability, including a shrapnel wound was not mentioned. When the veteran was examined by VA in September 1988, however, it was reported that he was status post a shrapnel wound of the right knee, but it was also reported that his history was difficult to elicit. In January 1990, the veteran underwent a follow-up examination to his Prisoner-of-War Protocol Examination partly for the purpose of determining whether he had specific joint problems as a result of claimed trauma to the knees, shoulders and neck while a prisoner of war. It is notable that a right knee disorder, including scars from shrapnel wounds, was not found on clinical examination. Although X-rays were interpreted as showing slight spurring of the superior right patella without joint effusion, a traumatic etiology for the spurring was not shown. The pertinent assessment was generalized osteoarthritis. When the veteran testified at the RO in July 1990, he asserted that he tripped while running in a cabbage patch and fell, injuring his right knee. He said that the Germans "fixed" his right knee following his capture. On VA field examination in February 1993, however, the veteran claimed that he had sustained shrapnel or bullet wounds of his right knee and that he was treated for this while a prisoner of war. On orthopedic examination by VA in August 1993, it was reported that the veteran attributed a small scar in the right popliteal area below the knee to a ricocheting shell fragment, presumably that struck him in service. However, the examiner did not diagnose any right knee disorder, nor did he attribute the right knee scar to service. When the veteran was examined by VA in August 1994, the veteran again attributed a scar in the right popliteal space to shrapnel injury in service and again claimed that he received emergency care for wounds of the right knee after he became a prisoner of war. Clinical examination of the knee, however, revealed no deficits, and X-rays of the right knee were similarly negative. Although the diagnoses included status post superficial shrapnel injury of the right knee, it is clear that this diagnosis is based entirely on history furnished by the veteran. There is with this issue, as with others, substantial reason to doubt this history, especially in view of the fact that right knee scars were not shown when the veteran was twice examined in the months following his repatriation to Allied control. It is notable that the claimed right knee shrapnel wounds were not mentioned by the veteran until many years following service, and there is no persuasive evidence that he somehow suppressed his memory of the claimed disorder until he testified at the RO in July 1990, despite the contentions of his representative at that hearing. Thus, the recent attribution of a right knee disorder to service, based solely on history, is no better than the facts asserted by one who has been found by a number of examiners to be a poor historian with respect to his disabilities. Elkins v. Brown, 5 Vet.App. at 478; Reonal v. Brown, 5 Vet.App. at 460-61; Swann v. Brown, 5 Vet.App. at 233. Insofar as the Board rejects the factual basis for the recent diagnosis of a right knee disorder attributable to service, the Board rejects the etiological opinion underlying the diagnosis. As right knee arthritis resulting from trauma in service is not shown by the record, service connection on a presumptive basis for post-traumatic arthritis of the right knee is not warranted under 38 U.S.C.A. § 1112(b). The Board therefore concludes that the preponderance of the evidence is against the claim for service connection for a right knee disorder, including residuals of shrapnel wounds of the right knee. C. Neck Disorder As with his previous claimed disorders, the veteran alleges that he has a chronic neck disorder acquired during service. He reported on a VA social work survey in 1986 that he injured his neck diving into a foxhole shortly before his capture by the Germans. But Dr. Cyr did not mention any neck complaints when he reviewed the veteran's recent medical problems in a letter dated in August 1988, although other joints were mentioned. In July 1990, he testified that during his internment as a prisoner of war, he was often beaten about the head and shoulders with a club or rifle butt and he attributed his neck disorder to mistreatment at the hands of his guards. But when examined by VA only a few months before, in January 1990, the veteran did not describe any trauma to his neck when he complained of neck pain. The diagnoses at that time included generalized osteoarthritis. When the veteran was examined by VA in August 1994, severe degenerative joint disease of the cervical spine was found on X- ray examination. The veteran gave a history of having injured his neck diving into a foxhole in December 1944 during the Battle of the Bulge. The examiner initially indicated that whether the cervical spine spondylosis could be attributed to service at that point in time was questionable but that there was nothing radiographically that would unequivocally link the findings in the cervical spine to trauma. In an addendum dated later the same month, the examiner stated that the veteran's degenerative joint disease of the cervical spine could not be linked to trauma in World War II. The record demonstrates that the service medical records, including two reports of physical examination after the veteran's return to military control, are negative for complaints or findings of any neck or cervical spine disorder. Although examined or treated on numerous occasions following service by VA and private physicians, the earliest indication of a neck disorder is on the Prisoner-of-War Protocol Examination performed by VA in January 1986, when the veteran complained of stiffness in his neck. However, a cervical spine disability was not diagnosed. When the veteran was hospitalized at a VA facility in April and May 1964 for treatment of an unrelated disability, it was reported that the veteran was a poor historian. It is therefore significant that when he was examined by VA in May 1956, at a time closer to service, his complaints were specific as to the disorders he sustained in service and the treatment he received in a prisoner of war camp, but these complaints omitted any mention of a neck disorder, nor were any complaints or findings of a neck disorder shown when the veteran was hospitalized from December 1952 to May 1953 for treatment of a fracture of the left patella. When the veteran was privately hospitalized in September and October 1975, it was reported that he described "bizarre pains in his upper abdomen, sometimes into his neck, sometimes into the right lower quadrant." On examination, however, the neck was negative for pertinent pathology. Dr. Johnson in a statement dated in January 1982 reported that the veteran had a multitude of complaints but found that his neck was negative on examination. On private orthopedic consultation in August 1990, it was reported that the veteran had had a problem for the past month involving neck pain radiating to the right upper extremity. A diagnostic workup revealed extensive spondylosis of the cervical spine. The examiner felt that at that point, the process was a degenerative one, and he did not attribute it to service or to trauma in service. The record is thus devoid of credible evidence to show that a neck disorder, including degenerative joint disease of the cervical spine, was present in service or until many years following service and is likewise devoid of evidence showing that degenerative joint disease of the cervical spine resulted from trauma in service or is otherwise related to service. In these circumstances, the Board finds that the preponderance of the evidence is against the claim for service connection for a neck disorder, including degenerative joint disease of the cervical spine. D. Evidence of Service Connection Under 38 C.F.R. § 3.304(d) As the veteran had combat service during World War II, the provisions of 38 C.F.R. § 3.304(d) (1994) must be considered. This regulation provides that satisfactory lay or other evidence that an injury or disease was incurred or aggravated as a result of combat service will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service, even though there is no official record of such incurrence or aggravation. The evidence in this case does not show that the left shoulder, right knee and neck disorders for which service connection is now sought resulted from combat service. The assertions of the veteran to that effect are unpersuasive. As indicated above, the veteran underwent at least two physical examinations following his repatriation, but these examinations do not show complaints or findings referable to any of the musculoskeletal disorders at issue on this appeal. Furthermore, the record is silent regarding the claimed disorders for many years following service. The only evidence attributing them to service are the statements of the veteran rendered at a time when compensation was being sought, when he was in fact complaining about being undercompensated by VA for his various disabilities, or after numerous evaluations had indicated that he was a poor historian regarding his claimed disabilities. In fact, the record shows that the veteran has been inconsistent concerning the circumstances in which he sustained his left shoulder, right knee and neck injuries. The record also suggests that he has a significant memory deficit. At this far removed from service, his statements and testimony regarding the onset of his disabilities cannot be relied on for purposes of establishing entitlement to service connection. There is, for example, no convincing evidence whatsoever to support the veteran's claim that he sustained shrapnel wounds of the knees and a bullet wound of the right arm during service. The service medical records, which almost certainly would have noted these wounds, are completely devoid of any reference to them, as well as the post service medical evidence for many years following separation. It bears emphasis that establishing an etiological relationship between claimed trauma in service and a disability shown many years after service requires medical expertise that the veteran lacks. See Grottveit v. Brown, 5 Vet.App. 91, 92-93 (1993); Espiritu v. Derwinski, 2 Vet.App. 492, 494-95 (1992). In this sense, the veteran's assertions of an etiological relationship to service constitute unsatisfactory evidence of service connection, even if they were credible or otherwise reliable. II. Secondary Service Connection for a Bladder Disorder The threshold question to be answered with respect to this aspect of the veteran's appeal is whether he has presented evidence of a well-grounded claim for secondary service connection for a bladder disorder. 38 U.S.C.A. § 5107(a). A well-grounded claim is a claim that is plausible, that is, one that is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). If a claim is not well grounded, the appeal must fail with respect to it, and there is no duty to assist the veteran further in the development of facts pertinent to the claim. Id. The service medical records are negative for complaints or findings of a bladder disorder. The veteran primarily contends, however, that he has a bladder disorder as a result of a lifetime of taking medication for his service-connected disabilities. He testified to this effect at the RO in July 1990, indicating that he believed that one of his treating physicians had linked his bladder disorder to his medication. The record shows that the veteran has been taking medication for a variety of disabilities for many years, although often not only for service-connected disabilities. The record shows that the veteran was admitted to a VA hospital in September 1981, where he gave a history of intermittent nocturia in recent years. Although he experienced some urgency at times, he had no hematuria. He underwent a left hydrocelectomy later the same month. Hematuria was found on a Prisoner-of-War Protocol Examination in January 1986. He was subsequently seen on numerous occasions for a variety of complaints, including chronic nocturia. When privately hospitalized in August 1989, he complained of weakness and difficulty voiding. On a report of consultation at that time, Dr. Ho indicated that he had seen the veteran the previous February, when some microscopic hematuria was found. An intravenous pyelogram had revealed a defect in the base of the urinary bladder with the bladder being trabeculated. Dr. Ho said that he had recommended a transurethral resection of the prostate but that the veteran had wanted to wait. His symptoms became progressively worse, however, and the veteran indicated that for the previous several weeks he had been unable to urinate and had pain in the suprapubic area, referred to the back. He was admitted and found to have an enlarged prostate. A transurethral resection of the prostate was performed. The diagnoses at discharge included acute renal insufficiency, urinary tract infection, obstructive uropathy with urinary retention, benign prostatic hypertrophy and chronic renal insufficiency, but none of his genitourinary problems was attributed by competent medical personnel to medication received for treatment of his service- connected disabilities. Indeed, the VA examiner in January 1990 was of the opinion that there was no evidence of a link between the veteran's obstructive uropathy and medications for his service-connected psychiatric disability. Although the veteran has been treated for years with multiple medications, the record does not contain competent medical evidence or opinion attributing any chronic bladder disorder to medication received for service-connected disabilities. It was reported on a VA urology examination in August 1993 that the veteran continued to experience frequent voiding at night, with urination varying from two to six times a night. The voiding force was usually satisfactory, although it was sometimes reduced. Although the examiner noted the veteran's urinary problems, especially the variability of his voiding pattern, he did not attribute these problems to medication received to treat service-connected disabilities. It is notable that he prescribed a tricyclic antidepressant for its desired side effect of reducing the veteran's irritative voiding symptoms. The Board notes that the VA examiner in August 1993 related an irritable bladder with lower abdominal discomfort and voiding problems to "the 10-year aggravation of his [the veteran's] having to stop work early because of a disability burden put upon him by the Veterans Administration." It is not shown, however, that VA was responsible for the veteran's departure from his job with the railroad in the early 1980's. On VA examination in March 1982, the veteran indicated that he had not worked since the previous August, that he was on sick leave from the railroad, and that the railroad had told him that it wanted him to return to work. The veteran reportedly stated that "Togus wrote the railroad a letter that the veteran is not able to work." But the record, as a whole, shows that the veteran was granted disability retirement from the railroad because of the cumulative effects of his organic and psychiatric disabilities, only some of which were service connected. It is unlikely that the veteran would have been granted a disability pension by the Railroad Retirement Board unless he had requested it or that VA would have written his employer concerning his physical condition unless he also requested it, especially in view of the provisions of federal law rendering such information confidential. If his employer actually wanted him to return to work, it was likely the veteran's actions, not VA's, that resulted in his being retired on disability from the railroad. As the Board has had cause to remark above, an etiological relationship such as that indicated here is only as good as the history upon which it is based, and where that history is factually inexact, exaggerated or unreliable, the etiology for the claimed disorder cannot be regarded as established. Elkins v. Brown, 5 Vet.App. at 478; Reonal v. Brown, 5 Vet.App. at 460- 61; Swann v. Brown, 5 Vet.App. at 233. Neither the veteran nor his representative is competent to render an etiological opinion where medical expertise is called for, and this is equally true where the claim is one of secondary service connection, including secondary service connection claimed as a result of treatment with medication for service-connected disability. Jones v. Brown, 7 Vet.App. 134, 137 (1994); Grottveit v. Brown, 5 Vet.App. at 92-93. The record, viewed in its entirety, does not provide competent medical evidence that the veteran has a bladder disorder as a consequence of medication received for treatment of his service- connected disabilities. In the absence of such evidence, the claim is not well grounded. Id. III. The Claim for a Total Compensation Rating A total compensation rating may be assigned where the schedular rating is less than total when it is found that the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. The record shows that the veteran has no more than a seventh grade education. He has occupational experience primarily in laboring jobs requiring significant physical exertion. He last worked full time for a railroad in the early 1980's. Service connection is in effect for a generalized anxiety disorder with conversion symptoms, depressed features, somatization and post-traumatic stress disorder, evaluated as 50 percent disabling; postoperative residuals of a vagotomy and pyloroplasty for a gastric ulcer, evaluated as 20 percent disabling; and arthritis of the left knee due to trauma as a prisoner of war, evaluated as 10 percent disabling. The combined service-connected evaluation has been 60 percent since August 1987. The record shows that the veteran is an unreliable historian as to the origin and extent of his symptoms, whether related to service-connected or nonservice-connected disabilities. The record also shows unequivocally that the veteran has quite a number of nonservice-connected disabilities, including coronary artery disease, chronic obstructive pulmonary disease, headaches, genitourinary disability, a back disorder, a right ankle disorder, bilateral calcaneal fracture residuals and generalized arthralgias. The veteran's overall physical decline is no doubt partly a product of age. See 38 C.F.R. § 4.19 (1994). The record also shows, however, that his physical complaints have considerable emotional overlay. Indeed, the record over the last several years is replete with complaints of physical ailments that appear to be manifestations of the service-connected psychiatric disability. Anxiety is the principal theme running through the veteran's complaints of organic disease in recent years, and a generalized anxiety disorder is usually diagnosed. Thus, while the actual maladies of which the veteran complains are often not service connected, his persistent complaints and exaggerated symptomatology appear to represent a significant manifestation of the service-connected psychiatric disability, especially in view of the fact that conversion symptoms and somatization have been associated with the service-connected psychiatric disability. On VA psychiatric examination in December 1988, moreover, the examiner was of the opinion that the veteran was unemployable solely as a result of his service-connected psychiatric disability. Previous psychiatric evaluations by VA have noted a defective fund of general and school information, and the veteran has been found to be deficient in arithmetic orally and to exhibit scattered memory deficits. It seems clear that the veteran's service-connected disabilities preclude any significant physical exertion. In view of his limited formal education and his substantial psychiatric impairment, the Board is of the opinion that sedentary employment in a job that is more than marginal is probably also precluded. In these circumstances, the Board concludes that a total compensation rating is warranted. ORDER New and material evidence not having been received, the application to reopen a claim of entitlement to service connection for a left shoulder disorder is denied. Service connection for a right knee disorder is denied. Service connection for a neck disorder, including degenerative joint disease of the cervical spine, is denied. Evidence of a well-grounded claim not having been received, the claim for service connection for a bladder disorder secondary to medication received for service-connected disabilities is dismissed. A total rating based on unemployability due to service-connected disabilities is granted, subject to controlling regulations governing the payment of monetary awards. ROBERT E. SULLIVAN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.