Citation Nr: 0006326 Decision Date: 03/09/00 Archive Date: 03/17/00 DOCKET NO. 96-28 712 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Honolulu, Hawaii THE ISSUES 1. Entitlement to an increased evaluation for chondromalacia of the right knee, currently evaluated as 10 percent disabling. 2. Entitlement to an initial evaluation in excess of 10 percent for degenerative changes of the right knee. 3. Entitlement to service connection for a right foot disorder, to include as secondary to the veteran's service- connected left large toe injury. 4. Entitlement to service connection for a right shoulder disorder, to include as secondary to the veteran's service- connected left large toe injury. 5. Entitlement to service connection for a left hip disorder, to include as secondary to the veteran's service- connected left large toe injury. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD A. C. Mackenzie, Associate Counsel INTRODUCTION The veteran served on active duty from January 1976 to January 1980 and from July 1985 to March 1992. This matter comes before the Board of Veterans' Appeals (Board or BVA) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii in May 1995 and September 1997. In a subsequent December 1998 rating action, the RO confirmed the 10 percent evaluation assigned for chondromalacia of the right knee but assigned a separate 10 percent evaluation for degenerative changes of the right knee. See VAOPGCPREC 9-98 (August 14, 1998); VAOPGCPREC 23-97 (July 1, 1997). Both evaluations have since remained in effect and are at issue in this case. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Also, the Board would point out that while the RO, in the appealed May 1995 rating decision, initially denied the claims for service connection solely on a direct service connection basis, these claims were expanded to include consideration on a secondary service connection basis in a February 1999 Supplemental Statement of the Case. The veteran's claims on appeal also initially included entitlement to an increased evaluation for a low back disorder, but the veteran withdrew this claim from appellate status during his June 1999 VA Travel Board hearing. See 38 C.F.R. § 20.204 (1999). FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of this appeal has been obtained by the RO. 2. The veteran's chondromalacia of the right knee currently is mild and is not productive of more than slight recurrent subluxation or lateral instability. 3. The veteran has been diagnosed with degenerative changes of the right knee, and this disorder has been shown to be productive of crepitus and range of motion from zero to 120 degrees. 4. The evidence of record, taken as a whole, does not show a causal relationship between the veteran's current right foot disorder and either service or a service-connected disability. 5. There is no competent medical evidence of a nexus between a current right shoulder disorder and either service or a service-connected disability. 6. There is no competent medical evidence of a nexus between a current left hip disorder and either service or a service- connected disability. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for chondromalacia of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (1999). 2. The criteria for an initial evaluation in excess of 10 percent evaluation for degenerative changes of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (1999). 3. A right foot disorder was not incurred in or aggravated by service, may not be presumed to have been incurred in service, and is not proximately due to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (1999). 4. The claim of entitlement to service connection for a right shoulder disorder, to include as secondary to the veteran's service-connected left great toe disorder, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 5. The claim of entitlement to service connection for a left hip disorder, to include as secondary to the veteran's service-connected left great toe disorder, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Entitlement to increased evaluations for chondromalacia and degenerative changes of the right knee As a preliminary matter, the Board finds that the veteran's claims for higher evaluations for chondromalacia and degenerative changes of the right knee are plausible and capable of substantiation and are therefore well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). A claim that a service-connected condition has become more severe is well grounded when the claimant asserts that a higher rating is justified due to an increase in severity. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 631-32 (1992). The Board is also satisfied that all relevant facts have been properly developed and that no further assistance to the veteran is required in order to comply with the VA's duty to assist him in developing the facts pertinent to his claims under 38 U.S.C.A. § 5107(a) (West 1991). In an October 1992 rating decision, the RO granted service connection for chondromalacia of the right knee on the basis of service medical records showing treatment for this disorder during service. A noncompensable (zero percent) evaluation was assigned, effective from March 1992. In the appealed September 1997 rating decision, the RO increased this evaluation to 10 percent, effective from April 1996. Also, a 100 percent evaluation was granted on the basis of post-surgical convalescence under 38 C.F.R. § 4.30 for the period from May 22 until July 1 in 1996. The underlying 10 percent schedular evaluation has since remained in effect and is at issue in this case, as well as the separate 10 percent evaluation for degenerative changes of the right knee, in effect since July 1997. In an April 1996 statement, Gerard H. Dericks, Jr., M.D., noted that the veteran had complained of difficulty with his right knee. An examination revealed tenderness of both medial and lateral joint lines, with no significant interarticular effusion. The ligaments were grossly intact, and there was full range of motion with tenderness. X-rays revealed mild degenerative joint changes. The assessment was traumatic arthritis of the right knee, with possible loose bodies. Subsequently, in May 1996, Dr. Dericks performed debridement and shaving of the right knee, with operative lateral release. This surgery revealed the patellofemoral joint to be "quite markedly laterally subluxed," but the veteran was noted to be stable in recovery. In October 1997, the veteran underwent a VA bones examination, during which he complained of constant right knee pain. Crepitus was noted, but there was no evidence of effusion, warmth or redness. The examination revealed laxity of the right knee, particularly on displacing the knee medially. There was "some laxity" on anterior/posterior displacement. Range of motion studies revealed flexion to 120 degrees and extension to zero degrees. The examiner noted that the veteran was wearing bilateral elastic knee supports. Knee jerk reflexes were brisk but symmetric. The pertinent assessment was a post-operative right knee partial rupture anterior cruciate ligament, with mild chondromalacia. A January 1998 magnetic resonance imaging (MRI) study also revealed mild degenerative changes of the medial femoral condyle, with a grade III chondromalacia patella present overlying the distal femur and a complex tear of the posterior horn of the medial meniscus. During his June 1999 VA Travel Board hearing, the veteran testified that his right knee problems included instability, inflammation, and swelling. He reported that he used a knee brace "quite often." He also described pain and stated that he avoided activities that had the effect of aggravating his knee symptoms. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). But see generally Fenderson v. West. 12 Vet. App 119 (1999) (concerning the application of "staged" ratings in certain cases in which a claim for a higher evaluation stems from an initial grant for service connection for the disability at issue). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (1999). The RO has evaluated the veteran's right knee chondromalacia at the 10 percent rate under 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1999). Under Diagnostic Code 5257, slight recurrent subluxation or lateral instability of the knee warrants a 10 percent evaluation, while moderate recurrent subluxation or lateral instability of the knee warrants a 20 percent evaluation. The United States Court of Appeals for Veterans Claims (Court) has held that Diagnostic Code 5257 contemplates the criteria of 38 C.F.R. §§ 4.40 and 4.45 (1999), which concern the applicability of a higher evaluation in cases of such symptomatology as painful motion, flare-ups and functional loss due to pain. Johnson v. Brown, 9 Vet. App. 7, 11 (1996); but see DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1996) (concerning the applicability of 38 C.F.R. §§ 4.40 and 4.45 (1999) in cases where a musculoskeletal code section is predicated on limitation of motion). Also, the RO has evaluated the veteran's right knee degenerative changes at the 10 percent rate under Diagnostic Code 5010. Under Diagnostic Code 5010, arthritis due to trauma and substantiated by x-ray findings is rated as degenerative arthritis under Diagnostic Code 5003. Under this code section, degenerative arthritis established by x- ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined and 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. In reviewing the evaluations for the veteran's chondromalacia and degenerative changes of the right knee, the Board observes that there is evidence of laxity on displacing the knee medially, without effusion or redness. While the veteran's patellofemoral joint was noted to be markedly laterally subluxed at the time of his May 1996 surgery, this degree of lateral subluxation has not been noted at any time during the pendency of this appeal, aside from the period during which a 100 percent evaluation was assigned for convalescence under 38 C.F.R. § 4.30. On VA examination in October 1997, the chondromalacia was assessed "mild." Overall, the Board finds that this disability is more accurately evaluated as slight rather than as moderate in degree. 38 C.F.R. § 4.7. As such, the criteria for an evaluation in excess of 10 percent under Diagnostic Code 5257 for chondromalacia of the right knee have not been met. As to the veteran's service-connected degenerative changes of the right knee, the RO, in the December 1998 rating action assigned a 10 percent evaluation on the basis of functional impairment of the joint. See 38 C.F.R. §§ 4.40, 4.45 (1999); DeLuca v. Brown, 8 Vet. App. at 204-07. Other right knee symptomatology has been shown to include range of motion from zero to 120 degrees and crepitus. There is no evidence of ankylosis of the right knee at a favorable angle in full extension, or in slight flexion between zero and 10 degrees (the criteria for a 30 percent evaluation under Diagnostic Code 5256); dislocated semilunar cartilage, with frequent episodes of "locking," pain, and effusion into the joint (the criteria for a 20 percent evaluation under Diagnostic Code 5258); flexion limited to 30 degrees (the criteria for a 20 percent evaluation under Diagnostic Code 5260); or extension limited to 15 degrees (the criteria for a 20 percent evaluation under Diagnostic Code 5261). Overall, the Board finds that the preponderance of the evidence is against the veteran's claims for an evaluation in excess of 10 percent for chondromalacia of the right knee and for an initial evaluation in excess of 10 percent for degenerative changes of the right knee. In reaching its determination on the latter claim, the Board finds that the evidence does not raise the question of whether a higher evaluation was warranted for any periods of time following the initial grant of service connection so as to warrant "staged" ratings due to a significant change in the level of disability. Rather, the symptomatology reported during the pendency of this appeal, as pertinent to this separately assigned rating, has remained essentially constant, with the degree of severity at all times fully contemplated by the assigned evaluation. Moreover, the veteran has not alleged, and the record does not demonstrate, that any recent findings were used in any way to deprive him of a higher rating for degenerative changes of the right knee when he was originally evaluated by the VA. See Fenderson v. West, supra. The Board has based its decision in this case upon the applicable provisions of the VA's Schedule for Rating Disabilities. The evidence does not demonstrate that the veteran's service-connected right knee disabilities have markedly interfered with his employment status beyond that interference contemplated by the assigned evaluations, and there is also no indication that these disorders have necessitated frequent periods of hospitalization during the pendency of this appeal. The veteran was grated a temporary 100 percent evaluation under 38 C.F.R. § 4.30 from May 22 until July 1 in 1996 because of his right knee surgery in May 1996, and he has not been hospitalized for right knee problems subsequently. As such, the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) (1999) for extra- schedular ratings are not in order. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 94-95 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). II. Claims for service connection A. Applicable laws and regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303(a) (1999). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Also, certain chronic diseases, including arthritis, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active military service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). Additionally, a disability which is proximately due to, or results from, another disease or injury for which service connection has been granted shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (1999). Specifically, when aggravation of a disease or injury for which service connection has not been granted is proximately due to, or the result of, a service-connected condition, the veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The initial question which must be answered in this case, however, is whether the veteran has presented well-grounded claims for service connection. In order for a claim for service connection to be well grounded, the claim must be shown to be at least plausible and capable of substantiation. Specifically, there must be: (1) a medical diagnosis of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). The nexus requirement may be satisfied by evidence showing that a chronic disease subject to presumptive service connection was manifested to a compensable degree within the prescribed period. See Traut v. Brown, 6 Vet. App. 495, 497 (1994); Goodsell v. Brown, 5 Vet. App. 36, 43 (1993). Where the determinative issue involves medical causation or etiology, or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" or "possible" is required. Epps v. Gober, 126 F.3d at 1468. Furthermore, in determining whether a claim is well grounded, the supporting evidence is presumed to be true and is not subject to weighing. King v. Brown, 5 Vet. App. 19, 21 (1993). In regard to establishing a well-grounded claim, the second and third Epps and Caluza elements (incurrence and nexus evidence) can also be satisfied under 38 C.F.R. § 3.303(b) (1999) by: (1) evidence that a condition was "noted" during service or during an applicable presumption period; (2) evidence showing post-service continuity of symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). Symptoms, not treatment, are the essence of evidence of continuity of symptomatology. Savage v. Gober, 10 Vet. App. at 496. Moreover, a condition "noted during service" does not require any type of special or written documentation, such as being recorded in an examination report, either contemporaneous to service or otherwise, for purposes of showing that the condition was observed during service or during the presumption period. Id. at 496-97. However, medical evidence noting the specific symptomatology is required to demonstrate a relationship between the present disability and the demonstrated continuity of symptomatology unless such a relationship is one for which a lay person's observation is competent. Id. at 497. In the case of a disease only, service connection also may be established under 38 C.F.R. § 3.303(b) (1999) by: (1) evidence of the existence of a chronic disease in service or of a disease, eligible for presumptive service connection pursuant to statute or regulation, during the applicable presumption period; and (2) present disability from it. Savage v. Gober, 10 Vet. App. at 495. Either evidence contemporaneous with service or the presumption period, or evidence that is post-service or post-presumption period, may suffice. Id. B. Right foot disorder As a preliminary matter, the Board finds that the veteran's claim for service connection for a right foot disorder is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, this claim is plausible and capable of substantiation. The Board also finds that all relevant evidence necessary for an equitable disposition of the appeal has been obtained by the RO, and no further action on the part of the VA is necessary to comply with the VA's duty to assist the veteran with the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a). The veteran contends that his current right foot problems were incurred as a result of rigorous physical activity during service. During his June 1999 VA Travel Board hearing, the veteran testified that his "foot injuries" in service, including his service-connected left toe disorder, were related. The service medical records are consistent with the veteran's testimony that he was a competitive athlete and engaged in martial arts. He was treated in March 1992 for right foot pain, noted to be "off and on" for one month. An examination conducted in conjunction with these complaints, however, was described as normal. The first evidence of a post-service right foot disorder is a March 1993 Department of the Army medical examination statement, which indicates that the veteran injured his right foot as a result of a fall during a period of active duty for training. This injury was noted to be temporary in nature. The report of an October 1994 VA feet examination indicates that x-rays of the right foot revealed a minute calcaneal spur. The diagnoses were foot pain secondary to a heel spur, tendinitis of the left great toe area, and plantar fasciitis. In a September 1998, Grace D. Pascual, D.P.M., reported that an examination suggested many right foot problems, including plantar fasciitis, heel spur syndrome, a dislocated fifth metatarsophalangeal joint, bowing of hallux extensus tendons, and degenerative joint disease of the feet bilaterally, resulting from structural and positional malalignment of subtalar varus in both feet. Dr. Pascual noted the veteran's history of rigorous physical activity during service and stated that his foot problems were a result of trauma or repetitive microtrauma associated with weight distribution through prolonged periods of time on his feet. Also, Dr. Pascual offered the same conclusion in a statement dated in March 1999. Taking into consideration the opinion from Dr. Pascual, the Board referred this case to a Veterans Health Administration (VHA) physician for review of the veteran's claim folder and an opinion regarding the etiology of the veteran's current right foot disorder. In a January 1999 opinion, Matko Milicic, MD, Chief of orthopaedic surgery at a VA medical center, noted that the veteran's claims file had been reviewed. Dr. Milicic stated that "[t]he injury to the left great toe seems to have been insignificant" and that the veteran's examination at discharge from service was normal with regard to the right foot. The Dr. Milicic opined that the findings described in Dr. Pascual's letter, including plantar fasciitis, heel spur syndrome, a dislocated fifth metatarsophalangeal joint, and bowing of hallux extensus tendons, "cannot be related to the sustained fracture of the left great toe while in service." Furthermore, this orthopedist pointed out that Dr. Pascual had ascribed the structural and positional malalignment of the hind foot as being responsible for the veteran's foot problems. Although Dr. Milicic was unable to comment definitively on the effect of post-service activities on the veteran's present right foot complaints, the conclusion was that the veteran's right foot disorder "is not as likely due to service or to the residuals of his service-connected left great toe injury." In this case, the Board finds that there is both positive and negative evidence pertaining to the veteran's claim for service connection for a right foot disorder. The Board is cognizant of Dr. Pascual's opinion regarding the claimed relationship of the veteran's current right foot disorder to in-service activities, but Dr. Pascual's opinion is not supported by a any rationale. Moreover, there is no indication from her statements that Dr. Pascual had an opportunity to review the veteran's claims file, including his service medical records. By contrast, Dr. Milicic did have an opportunity to review the claims file. This orthopedist found no relationship between the veteran's current right foot disorder and either service or his service-connected left great toe disorder. Importantly, Dr. Milicic reviewed the information by Dr. Pascual and supported Dr. Milicic supported his opinion by recognizing the insignificance of the veteran's left great toe disorder and the lack of right foot symptomatology at discharge from service. Given the more thorough analysis and rationale provided by Dr. Milicic, the Board finds that the January 1999 VA opinion is of significantly greater probative value than the statements from Dr. Pascual. See Hayes v. Brown, 5 Vet. App. 60, 69 (1993); Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992) ("It is the responsibility of the BVA to assess the credibility and weight to be given the evidence"). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) and Wray v. Brown, 7 Vet. App. 488, 493 (1995) (the Board may adopt a particular expert medical opinion where the expert has fairly considered the material evidence that appears to support the appellant's position). After weighing these opinions, the Board finds that the medical evidence of record, taken as a whole, supports the conclusion that the veteran's right foot disorder was not incurred as a result of service or incurred or aggravated secondary to his service-connected left great toe disorder. The only other evidence of record supporting the veteran's claim is his own lay opinion. As a layperson, however, he can testify as to his symptoms but he is not competent to provide testimony regarding matters of medical causation which require medical expertise. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). See also LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (evidence which is simply information recorded by a medical examiner and unenhanced by any additional medical commentary from that examiner does not constitute competent medical evidence); Robinette v. Brown, 8 Vet. App. 69, 77 (1995) (a lay account of a physician's statement, "filtered as it [is] through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute 'medical' evidence"). Overall, the Board finds that the preponderance of the evidence of record is against the veteran's claim of entitlement to service connection for a right foot disorder, to include as secondary to his service-connected left great toe injury. As such, this claim must be denied. In reaching this determination, the Board has considered the doctrine of reasonable doubt, as set forth in 38 U.S.C.A. § 5107(b) (West 1991). However, as the preponderance of the evidence is against the veteran's claim, this doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). C. Right shoulder and left hip disorders As to these claims, the veteran has alleged that he incurred both right shoulder and left hip disorders as a result of service. During his June 1999 hearing, the veteran contended that his right shoulder disorder was incurred in service and he described intense physical activity. He also asserted that his constant running in service caused undue stress and injury to his left hip. The service medical records do not document complaints of, or treatment for, right shoulder or left hip symptomatology during service. After service, the veteran was treated for complaints of left hip pain in February 1993 following a period of active duty for training, but this injury was noted to be temporary in nature. The veteran's October 1994 VA orthopedic examination contains diagnoses of recurrent shoulder subluxation, right greater than left; and symptomatic degenerative joint disease of the hips, right greater than left. However, neither this examination report nor any of the other evidence of record, including an April 1997 statement from Clifford K. H. Lau, M.D., which includes diagnoses of these disorders, provides an opinion to the effect that these disorders were related either to service or to a service-connected disability. Also, with respect to the presumptive period, the diagnosis of degenerative joint disease of the hips was rendered more than two years following the veteran's separation from service and thus was beyond the applicable time. In this case, there is no competent medical evidence of a nexus or link between the veteran's current right shoulder and left hip disorders and either service or a service- connected disability. Indeed, the only evidence of record suggesting such a nexus is the lay evidence of record, described above, but this is a matter requiring expert medical opinion. See Espiritu v. Derwinski, 2 Vet. App. at 494-95; see also LeShore v. Brown, 8 Vet. App. at 409; Robinette v. Brown, 8 Vet. App. at 77. Therefore, the lay contentions do not provide a sufficient basis upon which to find these claims to be well grounded. See Grottveit v. Brown, 5 Vet. App. 91, (1993). Well-grounded claims must be supported by evidence, not merely allegations. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In the absence of competent medical evidence to support the veteran's claims for service connection for right shoulder and left hip disorders, both to include as secondary to his service-connected left great toe disorder, these claims must be denied as not well grounded. Since the veteran's claims are not well grounded, the VA has no further duty to assist the veteran in developing the record to support his claims. See Epps v. Gober, 126 F.3d at 1467-68 (Fed. Cir. 1997) ("there is nothing in the text of § 5107 to suggest that [VA] has a duty to assist a claimant until the claimant meets his or her burden of establishing a 'well grounded' claim"). The Board recognizes that the RO denied the veteran's claims for service connection for right shoulder and left hip disorders on their merits in the appealed May 1995 rating decision, while the Board has denied these claims as not well grounded. No prejudice to the veteran results in cases where the RO denies a claim for service connection on the merits and does not include an analysis of whether the veteran's claim is well grounded, and the Board denies the same claim as not well grounded. See Meyer v. Brown, 9 Vet. App. 425, 432 (1996) T he Board is not aware of the existence of additional relevant evidence that could serve to make the veteran's claims well grounded and require notification to the veteran that such evidence is needed to complete his application. See McKnight v. Gober, 131 F.3d 1483, 1484-85 (Fed. Cir. 1997). ORDER Entitlement to an increased evaluation for chondromalacia of the right knee, currently evaluated as 10 percent disabling, is denied. Entitlement to an initial evaluation in excess of 10 percent for degenerative changes of the right knee is denied. Entitlement to service connection for a right foot disorder, to include as secondary to a left great toe injury, is denied. A well-grounded claim not having been submitted, entitlement to service connection for a right shoulder disorder, to include as secondary to a left great toe injury, is denied. A well-grounded claim not having been submitted, entitlement to service connection for a left hip disorder, to include as secondary to a left great toe injury, is denied. CHARLES E. HOGEBOOM Member, Board of Veterans' Appeals