Citation Nr: 0003901 Decision Date: 02/15/00 Archive Date: 02/23/00 DOCKET NO. 96-25 765 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a respiratory disorder. 2. Entitlement to service connection for a skin disorder. 3. Entitlement to service connection for Lyme disease, including as due to undiagnosed illness. 4. Entitlement to service connection for chronic fatigue, including as due to undiagnosed illness. 5. Entitlement to an increased evaluation for a left knee disorder, currently rated 20 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechter, Associate Counsel INTRODUCTION The veteran served on active duty from January 1978 to December 1993. The appeal as to the issues of entitlement to service connection for a respiratory disorder and a skin disorder arise from a December 1998 Supplemental Statement of the Case of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey, denying those claims. The Board recognizes that these two claims arise in a technically incorrect posture. However, these claims were addressed at the veteran's hearing before the Board in November 1999. Inasmuch as the veteran is desirous of appealing these two issues, the fact that they have been the subject of a statement of the case, and the fact that the veteran's testimony at the Board hearing represents a timely appeal, the minimum requirements of due process have been met, and the Board is herein addressing these two issues on appeal. The issues of entitlement to service connection for Lyme disease, including as due to undiagnosed illness, and entitlement to service connection for chronic fatigue, including as due to undiagnosed illness, arise from the May 25, 1995 rating decision of the RO in Philadelphia, Pennsylvania, denying service connection for "Persian Gulf syndrome." In the course of appeal, including in particular in the veteran's testimony before the undersigned Board member at a hearing at the RO in November 1999, the veteran clarified this issue on appeal as entitlement to service connection for Lyme disease and chronic fatigue, both including as due to his exposure to conditions in the Persian Gulf, and in effect as due to undiagnosed illness. Accordingly, these two issues are also on appeal and herein addressed by the Board. The claim of entitlement to an increased rating for a service-connected left knee disorder arises from a May 1995 decision by the RO in Newark, New Jersey, granting service connection and assigning a 10 percent rating for a left knee disorder. In the course of appeal, by a December 1998 rating decision, the RO in Newark, New Jersey, granted an increase to a 20 percent disability rating for a left knee disorder. Also in the course of appeal, the veteran testified before a hearing officer at the RO in September 1997, as well as before the undersigned Board member at the RO in November 1999. Transcripts of both of those hearings are included in the claims folder. FINDINGS OF FACT 1. The veteran's claim of entitlement to service connection for a respiratory disorder is not plausible. 2. The veteran's claim of entitlement to service connection for a skin disorder is not plausible. 3. The veteran's claim of entitlement to service connection for Lyme disease, including as due to undiagnosed illness, is not plausible. 4. The veteran's claim of entitlement to service connection for chronic fatigue, including as due to undiagnosed illness, is not plausible. 5. The veteran's left knee disorder, based on synovitis with limitation of extension, exacerbations and flare-ups, pain and stiffness associated with use, is equivalent to limitation of extension to 15 degrees. CONCLUSIONS OF LAW 1. The veteran has not submitted a well-grounded claim for service connection for a respiratory disorder. 38 U.S.C.A. § 5107(a) (West 1991). 2. The veteran has not submitted a well-grounded claim for service connection for a skin disorder. 38 U.S.C.A. § 5107(a) (West 1991). 3. The veteran has not submitted a well-grounded claim for service connection for Lyme disease, including as due to undiagnosed illness. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.317 (1999). 4. The veteran has not submitted a well-grounded claim for service connection for chronic fatigue, including as due to undiagnosed illness. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.317 (1999). 5. The schedular requirements for a rating in excess of 20 percent for a left knee disorder have not been met, and were not met during the period from December 2, 1993, until the present. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.2, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5020, 5260, 5261 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. Claims for Entitlement to Service Connection Under pertinent law and VA regulations, service connection may be granted if a disorder was incurred or aggravated during service. 38 U.S.C.A. §§ 1110, 1131(West 1991); 38 C.F.R. § 3.303 (d) (1999). The initial question to be answered regarding the service connection claims on appeal is whether the appellant has presented evidence of well-grounded claims; that is, claims which are plausible. If he has not presented a well grounded claim, his appeal as to that claim must fail and there is no duty to assist him further in the development of that claim because such additional development would be futile. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet.App. 78 (1990). Although a well-grounded claim need not be conclusive, it must be accompanied by supporting evidence sufficient to justify a belief by a fair and impartial individual that the claim is plausible. Tirpak v. Derwinski, 2 Vet.App. 609 (1992). In order for a claim to be well grounded, there must be competent evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Tidwell v. West, 11 Vet. App. 242 (1998). Evidentiary assertions by the veteran must be accepted as true for the purposes of determining whether a claim is well grounded, except where the evidentiary assertion is beyond the competence of the person making the assertion. See King v. Brown, 5 Vet.App. 19, 21 (1993). However, lay persons are not competent to offer medical opinions. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Only medical evidence, and not the veteran's lay testimony, is cognizable for satisfying the third Caluza requirement, of evidence of a causal link between service and the current disorder claimed for entitlement to service connection. Caluza; Tidwell; Espiritu. 1. a. Service Connection for a Respiratory Disorder 1. a. 1) Factual Background In service in October 1988 the veteran was treated for complaints of persistent cough for the prior seven days, productive of thick, white sputum. Upon examination, there was no fever, the neck was supple without palpable nodes, and the tympanic membranes were clear bilaterally. The veteran was coughing, but there were no rhonchi or rales in the lungs. The throat was red and raw but without exudate. The examiner assessed bronchitis. Upon VA examination in February 1995, chest examination was normal. Upon VA general examination in June 1996 the veteran reported experiencing transient breathlessness waking him from his sleep. He also reported breathlessness on airplane flights while the airplane is in flight, but not upon takeoff or landing. Pulmonary function studies performed at the examination were normal. The examiner examined the veteran for difficulty breathing resulting from exposure to environmental hazards of the Persian Gulf War, but no such breathing difficulty was found. VA chest X-rays in April 1997 showed no evidence of active process, with stable appearance since the preceding examination. At a December 1997 VA examination, in pertinent part, the veteran reported having asthma for years which was initially discovered in service. He reported exposure to fumes on many occasions while in service. He reported having wheezing until now for the prior ten years, with occasional white or yellow sputum in the morning. He denied any history of cigarette use. Upon examination no allergies were noted. There was no evidence of current broncho-spasm. The veteran reported being able to walk two flights of stairs before having to rest. The examiner concluded that the veteran had broncho-spastic lung disease, with noted current use of an Albuterol inhaler, which relieved symptomatology. Severity of the disease was to be determined by pulmonary function tests. The veteran testified at a hearing before the undersigned Board member in November 1999. He testified that due to his lung condition he coughed to the point of gagging whenever smelling certain irritants, such as perfumes or gasoline, so that he then had difficulty continuing to breathe, and on occasion coughed up white matter that looked like cottage cheese. He testified that the condition had been called a bronchial irritant when diagnosed a couple of years ago. He testified that when he had a coughing attack he would have to stop, sit down, and focus on his breathing to catch his breath. He testified that he had the coughing spasms two or three times per week. He added that he lived five minutes from an Air Force base and sometimes the fumes from the base became an irritant. He testified that he first noticed the disorder in the Persian Gulf, where he worked in an air base region, with aircraft continually running and exposure to a lot of jet fumes to the point that they were becoming a skin irritant, burned his skin, and caused a lot of coughing. There was also the smell of burning oil in the evenings. However, he testified that he had some coughing spasms before that time, when he escorted airplanes at McGuire Air Force Base, with exposure to fumes and burning fuel. He testified that it was suggested that the problem was related to an acid reflux disorder, but the problem continued despite his taking Pepcid for the acid reflux disorder. He added that he had been prescribed an asthmatic puffer a few years ago, but he did not use it any more because the diagnosis was now associated with gastric irritation. He testified that he never had an emergency hospitalization for an asthmatic attack, but rather had always been able to regain control of his breathing by sitting, relaxing for a few hours, and calming down. 1. a. 2) Analysis The veteran has presented testimony to the effect that he was exposed to respiratory irritants in service, including jet fuel fumes, and has testified to a recurrent broncho-spastic condition, most recently associated with a gastric reflux disorder. He states that the disorder recurs two or three times per week, forcing him to stop and rest to regain his breathing. However, the service medical records show no chronic respiratory disorder. While a VA examiner in December 1997 concluded, based on the veteran's statements and his reported use of an Albuterol inhaler, that he suffered from broncho-spastic lung disease, no current respiratory disorder has been causally linked to the veteran's period of service. Thus while the first and second criteria under Caluza for a well-grounded claim - of an inservice disorder and a current disorder - may be judged satisfied based on the veteran's testimony and the December 1997 VA medical diagnosis, the third Caluza criterion of a causal link between service and the current disorder, has not been met. As all three Caluza criteria have not been satisfied, the veteran's claim of entitlement to service connection for a respiratory disorder must be denied as not well grounded. Caluza; Tidwell. 1. b. Service Connection for a Skin Disorder 1. b. 1) Factual Background In service in March 1987 the veteran was treated, in pertinent part, for a rash, apparently of the genitals, for the prior three to five days. The scrotum was slightly erythematous and the base of the glans of the penis was erythematous. The examiner assessed, in pertinent part, possible tinea. The examiner prescribed Lotrimin for the scrotum. At a February 1995 VA examination, the veteran's skin was normal. At an April 1997 VA examination, the veteran complained, in pertinent part, of blotchy redness which recurred on his face and neck and occasionally on his hands and ankles, with mild exacerbation upon sun exposure. He reported having flares once or twice per month, which he treated with a moisturizer. The examiner observed erythema and scale localized to the eyebrow and malar area. The scalp was relatively clear. The upper back had multiple follicular erythematous papules, and the trunk had multiple angiomatous papules. The backs of the hands and forearms were clear. The anterior calf had a keratotic verrucose papule. The examiner diagnosed seborrhea dermatitis, and explained that this was a chronic and common condition characterized by erythema and scale on the face and chest, treated with topical steroids. Also diagnosed were an angioma on the trunk, seborrheic keratosis on the left leg, and folliculitis on the back. At a September 1997 hearing before a hearing officer at the RO, the veteran testified that in service he developed skin rashes from small bite marks when he worked with sand bags in the Persian Gulf. He testified that the rashes would recur intermittently, and were exacerbated by sunlight. At the November 1999 Board hearing, regarding his skin disorder, the veteran testified that when he was working with sand bags in the Persian Gulf he and other soldiers developed what they first thought was a sunburn in the exposed parts of the skin around the hands and ankles, but which then developed into bumps like bites, and then spread out in a red rash with flaking. He testified that the medical technician had given them a white cream for the skin condition, and that he continued to use a cream for the condition which he believed was cortisone-based. He testified that the cream he used now was given to him by his general practitioner. He added that neither in service nor now did he recall a diagnosis for the skin disorder. He testified that now when exposed to the sun on his hands and face his skin became patchy like with the original exposure. He testified that the condition might develop twice a day or might not develop for a few weeks, but that sun exposure seemed to activate the condition. He testified that currently the condition was largely limited to the hands and face, was not present to any significant degree on the feet or ankles, and had not spread too far. He added that at a VA visit the physicians noted that the condition was also present on his back. He testified that the condition would sometimes last a few days, would not last long, and was not very irritating since he knew not to scratch it. He testified that he had not lost any work due to the condition. He added that his employers had switched his shift when there had been some concern about the skin condition. 1. b. 2) Analysis The veteran has presented medical evidence - an April 1997 VA examination -establishing the presence of multiple skin conditions. The veteran has testified to the presence of skin conditions in service. Hence the veteran has satisfied the first two Caluza criteria for a well-grounded claim: evidence of an inservice disorder and medical evidence of a current disorder. However, the veteran has not satisfied the third Caluza requirement for a well-grounded claim: cognizable (medical) evidence causally linking his period of service or inservice disorder to the current disorder. Aside from the March 1987 service medical record noting a scrotal condition, service medical records include no record of treatment for a skin condition. No skin disorder from service may be causally linked to a current skin disorder based on the medical evidence of record. Accordingly, absent medical evidence of such a causal link to service, the veteran's claim of entitlement to service connection for a skin disorder is not well grounded. Caluza; Tidwell. 1. c. and d. Service Connection for Lyme Disease and Chronic Fatigue, Including as Due to Undiagnosed Illness 1. c. and d. 1) Factual Background The veteran's Service Form DD214 notes service awards including a Kuwait Liberation Medal, and includes a notation that the veteran served in support of operation Desert Shield/Storm from August 1990 to December 1993. In service in April 1981 the veteran complained of persistent occipital, frontal, and bi-temporal headaches. He also noticed tight muscles in the posterior neck and decreased range of motion of the neck. Upon examination there was increased pain upon flexion of the neck. The examiner assessed a muscle contraction headache. In service in March 1987 the veteran was treated for complaints of a stiff neck and a rash, apparently of the genitals, for the prior three to five days. He also complained of headaches from moving his head. There was no history of trauma but the veteran reported moving furniture five days prior. Upon examination, the neck had full range of motion, there was no vertebral tenderness, deep tendon reflexes were intact, and the upper extremities had 5/5 strength. However, the right trapezius muscle was tender. The scrotum was slightly erythematous and the base of the glans of the penis was erythematous. The examiner assessed cervical strain and possible tinea. The examiner prescribed heat for the neck with aspirin as need for pain, and Lotrimin for the scrotum. Upon re-evaluation of the neck stiffness two days later, cervical spasm was assessed, and a prescription of Parafon Forte was added to his treatment. In service in November 1992, upon treatment for knee pain, the veteran also reported that he had worked in the woods, and had pulled a tick off his body. He reported recently feeling tired and flushed. He was oriented times three and denied any rashes. A Lyme titer was 0.71. The examiner assessed rule out Borrelia, and prescribed Doxycycline. At a February 1995 VA examination, the examiner was to evaluate the veteran for "Persian Gulf syndrome." However, the examiner noted that the veteran did not report multiple symptoms. While the veteran reported a past positive Lyme disease titer, a Lyme antibody titer at the examination was normal. Except for a slightly raised SGPT, laboratory studies were normal. Physical examination was also normal, with the examiner only diagnosing mild obesity. The skin, mental status, neuromuscular functioning, fundi, chest, and abdomen were normal. Joints were normal with the exception of orthopedic findings referable to the knees. At a June 1996 VA general medical examination, the veteran was noted to be claiming service connection for Lyme disease due to exposure to environmental hazards in the Persian Gulf War. However, at the examination a Lyme disease antibody titer was negative, and the veteran reported no current residuals of Lyme disease. The examiner diagnosed no Lyme disease found. He also diagnosed no burr scars found. At an April 1997 VA examination, the veteran reported, in pertinent part, persistent joint pains of the knees and elbows. However, the examiner made no pertinent findings. At a September 1997 hearing before a hearing officer at the RO, the veteran testified that since the Persian Gulf War he also had pain in multiple joints including his arms and neck, and a tingling sensation on the left side of his head. At the November 1999 Board hearing he testified that he had gone to his physician with symptoms including rashes, headaches, joint pain, and chronic fatigue, and the physician had immediately suspected Lyme disease. He added that a blood test was performed and he was put on antibiotics and told to report back in two weeks. However, when he returned in two weeks he was asked if he had been in the Persian Gulf. He added that he was told that he had a high tracer but that it wasn't Lyme disease. He added that he had been tested a few more times for Lyme disease, but a tracer was not indicative of Lyme disease. He testified that when he had fatigue and headaches he would lie down in his room in the dark and try to get some rest. He added that he took Tylenol Sinus for the headaches and that helped a lot, making the headaches tolerable. He testified that while in the Persian Gulf he had symptoms including rashes, headaches, not sleeping well, and jitteriness. He testified that he had in the past taken off up to two days at a time from work because he was tired or had severe headaches or other symptoms. He added that his chronic fatigue had been associated with a post-traumatic disorder. He was receiving counseling once per week at Marshall Hall at Fort Dix. 1. c. and d. 2) Analysis The Board first considers the veteran's claims of entitlement to service connection for Lyme disease and chronic fatigue on a direct basis. Service medical records show that the veteran was seen three times for complaints of symptoms possibly associated with Lyme disease or chronic fatigue. In April 1981 the veteran complained of headache symptoms and some muscle aches. However, the examiner then assessed a muscle contraction headache. That inservice treatment thus appears not to be related to either Lyme disease or chronic fatigue. In service in March 1987 the veteran complained of a stiff neck and a rash, but the rash noted to be limited to the genital area and the neck stiffness was assessed as cervical strain. Neither condition was medically associated with either Lyme disease or chronic fatigue. In service in November 1992, while the veteran reported a tick exposure and feeling tired and flushed, a Lyme titer was only 0.71, and the examiner assessed only rule out Borrelia. Post service, upon VA examinations in February 1995, June 1996, and April 1997, no neuromuscular deficits were found, no symptoms of Lyme disease were medically identified, and no diagnoses of Lyme disease or chronic fatigue were made. Lyme disease antibody titers in February 1995 and June 1996 were negative, and the June 1996 examiner noted that the veteran had not reported any current residuals of Lyme disease. Thus, while the veteran's testimony may be accepted to satisfy the second Caluza criterion of inservice presence of symptoms of Lyme disease or chronic fatigue, the first and third Caluza criteria for a well-grounded claim, of cognizable (medical) evidence of a current disorder and of a causal link between a current disorder and the veteran's period of service, are not satisfied for either Lyme disease or chronic fatigue. Accordingly, the veteran's claims of entitlement to service connection for Lyme disease and chronic fatigue on a direct basis do not satisfy the requirements of well-grounded claim. Caluza; Tidwell. The Board next considers the veteran's claims of entitlement to service connection for Lyme disease and chronic fatigue as due to undiagnosed illness, based on his service in the Persian Gulf region during the Persian Gulf War. Compensation for certain disabilities due to undiagnosed illnesses may be granted. The pertinent regulation, in its entirety, is as follows: (a)(1) Except as provided in paragraph (c) of this section, VA shall pay compensation in accordance with chapter 11 of title 38, United States Code, to a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of this section, provided that such disability: (i) became manifest either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2001; and (ii) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. (2) For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. (3) For purposes of this section, disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6- month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. (4) A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. (5) A disability referred to in this section shall be considered service connected for purposes of all laws of the United States. (b) For the purposes of paragraph (a)(1) of this section, signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: (1) Fatigue (2) Signs or symptoms involving skin (3) Headache (4) Muscle pain (5) Joint pain (6) Neurologic signs or symptoms (7) Neuropsychological signs or symptoms (8) Signs or symptoms involving the respiratory system (upper or lower) (9) Sleep disturbances (10) Gastrointestinal signs or symptoms (11) Cardiovascular signs or symptoms (12) Abnormal weight loss (13) Menstrual disorders. (c) Compensation shall not be paid under this section: (1) If there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or (2) If there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) If there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. (d) For purposes of this section: (1) The term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. (2) the Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (1999). Claims for service connection due to undiagnosed illness must still first satisfy the requirements of a well-grounded claim. As noted above, the veteran has not presented cognizable (medical) evidence of either current Lyme disease or current chronic fatigue. Caluza; Tidwell. Hence well- grounded claims for the disorders due to undiagnosed illness have not been presented. The further requirement of medical evidence of the presence of these disorders to a compensable degree, as an initial requirement of 38 C.F.R. § 3.317 (1999), is also not satisfied. 2. Entitlement to an Increased Rating for a Left Knee Disorder 2. a. Factual Background Service medical records reflect a history of difficulties with the left knee over many years. The veteran suffered injury to the left knee in October 1982, with a diagnosis of bruised and strained patella ligament. He underwent arthroscopic surgery in service in 1987, with chondroplasty of the patella and lateral retinacular release. The diagnosis at that time was chronic patellofemoral pain syndrome, status post these surgical interventions. The veteran had ongoing treatment in service for the knee with nonsteroidal anti-inflammatory medication, and was noted to have continued working in service on temporary profile despite pain in his knee with activity. In February 1988 the veteran suffered a meniscus tear and trauma to the medial collateral ligament of the left knee, treated with pain medications and physical therapy. An arthrogram in April 1988 revealed a lateral meniscus tear. In April 1988 the veteran had continued swelling and pain in the knee with episodes of locking with crunching and popping. He reported many episodes of buckling of the knee between April and September of 1988, with continued pain and swelling with each episode. The veteran re-injured the knee in September 1989 and again in January 1991. In October 1992 he was diagnosed with a medial meniscus tear. Upon re-evaluation in October 1992 the veteran's diagnosis was continued, and he was placed on permanent profile to restrict running. The orthopedic surgeon then opined that the veteran's condition was permanent and not amenable to further surgical intervention, with running, marching, jumping, and prolonged standing all restricted. Upon examination in service in June 1993 the veteran had full range of motion of the left knee without locking, with good medial and lateral stability and negative McMurray's sign. There was a positive patellar apprehension sign. The examiner recommended, based on the veteran's history, no worldwide qualification, a permanent profile, and a Medical Board evaluation. An August 1993 U.S. Air Force physical evaluation board found the veteran to suffer from a permanent, chronic patello- femoral pain syndrome, status post 1987 arthroscopy chondroplasty of the patella and lateral retinacular release, with a resulting 30 percent disability impairment rendering him unfit for duty. He was accordingly awarded a permanent disability retirement. At a February 1995 VA examination of the left knee, the veteran reported pain and aching in the knee with intermittent swelling. A history of inservice injury and surgical repair of the left knee with ongoing difficulties was noted. Upon examination, nontender surgical scars over the anterior aspect of the knee were observed. The knee flexed from zero to 140 degrees and extended to zero degrees. However, full passive flexion of the knee caused discomfort, as did passive rotary movement of the knee. The patella was freely moveable, and no undue laxity of ligaments of the knee were noted. The examiner diagnosed, in pertinent part, residuals of injury and post-operative residuals of arthroscopic surgery to the left knee, and left knee strain associated with intermittent synovial irritation and synovitis of the joint. At a June 1996 VA examination of the veteran's joints, the veteran reported a history of left knee pain since service, with the pain progressively worse over the years. He reported left knee swelling with over-exertion, giving out of the knee, and popping, snapping, and crackling noises in the knee. He reported increased pain upon walking, standing, or attempting to run, and during cold, damp weather. There was no swelling. However, there was mild global tenderness, extension to zero degrees, flexion to 95 degrees, and mild global laxity. The examiner diagnosed post-operative internal derangement of the left knee with mild decreased range of motion and global ligamentous laxity. Knee X-rays showed well-maintained joint spaces. In September 1997 the veteran testified before a hearing officer at the RO. He testified that he had pain and swelling in the knee which precluded athletic activities, such as running. He added that he had pain continually, which he treated with reduced activity, and on a few occasions with anti-inflammatory medication. He explained that he would take a few anti-inflammatories in the evening if he were on his feet all day. He testified that he might take a sick day from his work as a corrections officer because of his left knee, but that he seldom saw a doctor for the problem. He estimated that he took two sick days because of his left knee in the last year. However, he added that he had learned to adjust to the level of pain that he regularly had in the knee. He believed that he was at risk of not being able to perform physically to the extent required in cases of emergency in his work as a corrections officer, because of his left knee. He testified that at work his friends would also make some accommodations for him or trade duties to help accommodate him and his knee condition. He testified that that he elevated the knee to help it. At a December 1997 VA examination initially to evaluation other conditions, the veteran's history of difficulties with his knee was noted. The veteran reported easy fatigability, pain, stiffness, and instability in the knee, with sensitivity to cold and damp. He also reported that increased activity would result in with stiffness and instability in the knee, necessitating his sitting down. He reported that prolonged use including walking or standing precipitated stiffness and pain in the knee. He reported currently taking Naproxen with some relief. He reported having increased fatigability, weakness, and decreased range of motion in the knee with ongoing use. Upon examination, the veteran had a 5 degree extension deficit and flexion to 60 degrees, with further flexion resulting in significant pain. McMurray's and anterior and posterior drawer signs were negative, and there was no laxity. There were tenderness to palpation and evidence of bony distortion. There was no effusion. The examiner diagnosed, in pertinent part, arthralgias of the left knee. At a September 1998 VA examination of the veteran's joints, the veteran's history of service and his medical history referable to his left knee were noted. He reported having pain in the left knee on a daily basis. Arthroscopic surgery scars over the left knee were noted. The left knee had a 10 degree residual extension deficit, with flexion from 10 to 90 degrees. Further flexion was precluded by pain and stiffness. There was no evidence of instability, easy fatigability, or incoordination. The examiner assessed, in pertinent part, traumatic strain of the left knee joint. The examiner noted that the left knee was prone to exacerbation and flare-ups. At the November 1999 Board hearing the veteran testified that he injured his left knee in service while stationed in Alaska when he fell on an icy patch and twisted the knee. He testified that when he started air base ground defense tactical activities the knee started to bother him, so that there was a medical history of treatment for the knee beginning from 1982 to 1983. He testified that currently the left knee was always painful and swollen and was not as strong and stable as it had been prior to the injury. He added that he had undergone a few surgeries to clean up the area, and that he had been informed by his physician that with current medical techniques nothing further could be done to help the knee except pain medication, elevation, and message. He testified that he had previously been taking over-the-counter medication for the knee but that did not help much. However, he was currently taking Percocet for another condition, and that seemed to dull the pain. He added that he nonetheless still had pain every day. He testified that he had re-injured his left knee post service at work, and that his current disorders including of both knees and the right ankle combined to cause him to be currently on worker's compensation from his work as a corrections officer. He added that he had been going to a private physician for his left knee, but after he went on worker's compensation he was not getting as good care and accordingly started going to the VA hospital. He added that he would not be able to return to his work as a Federal corrections officer because it required being active. He testified that his general practitioner at Marshall Hall at Fort Dix was aware of his left knee disorder, as were doctors from Walson, and doctors Slipman and Vulvosalvage from the University of Pennsylvania. He explained that he received treatment at military facilities because he had disability retirement from the military, based on his left knee injuries. 2. b. Analysis Initially, the Board finds the appellant's claim well grounded pursuant to 38 U.S.C.A. § 5107 (West 1991) in that his claim is plausible. Murphy v. Derwinski, 1 Vet.App. 78 (1990). This finding is based on the appellant's evidentiary assertion that his service-connected disability has increased in severity. Proscelle v. Derwinski, 1 Vet.App. 629 (1992); King v. Brown, 5 Vet.App. 19 (1993). Once it has been determined that the claim is well grounded, the VA has a statutory duty to assist the appellant in the development of evidence pertinent to the claim. 38 U.S.C.A. § 5107. The Board is satisfied that all available evidence necessary for an equitable disposition of the appeal has been obtained. Under applicable criteria, disability evaluations are determined by the application of a schedule of ratings based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. 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. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). In evaluating service-connected disabilities, the Board looks to functional impairment. The Board attempts to determine the extent to which a service-connected disability adversely affects the ability of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. §§ 4.2, 4.10 (1999). Where an increase in the level of a service- connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet.App. 55 (1994). 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. 38 C.F.R. § 4.7 (1999). Based on medical findings, the veteran's left knee disorder may be rated under Diagnostic Code 5260 for limitation of flexion of the knee, or under Diagnostic Code 5261 for limitation of extension of the knee. 38 C.F.R. § 4.71a (1999). When reviewing the level of disability due to a service- connected disability affecting a joint, when the rating is based on limitation of motion, the Board must consider an increased schedular rating based on functional loss due to pain on undertaking motion, weakened movement, fatigability, and incoordination. 38 C.F.R. §§ 4.40 and 4.45 (1999); DeLuca v. Brown, 8 Vet.App. 202 (1995). In this case the veteran has been diagnosed with synovitis, which is rated analogous to degenerative arthritis and is appropriately rated under Diagnostic Code 5020. Under that Code, the veteran's synovitis is rated based on limitation of motion of the joint. In this case, both limitation of flexion and limitation of extension have been demonstrated, so that an entitlement to an increased based on both flexion and extension limitations must be considered. While the RO has rated the veteran for based on arthritis due to trauma, pursuant to Diagnostic Code 5010, and rated him based on other disability of the knee under Diagnostic Code 5257, the Board finds that ratings under Diagnostic Codes 5020, 5060, and 5061, for synovitis with limitation of flexion and extension, is the more appropriate course, as discussed below. When flexion of a knee is limited to 45 degrees, a 10 percent rating is assigned; when limited to 30 degrees, a 20 percent rating is assigned; and when limited to 15 degrees, a 30 percent rating is assigned. Diagnostic Code 5260. Upon recent VA examination in December 1997, flexion was limited to 60 degrees due to pain, and upon VA examination in September 1998, flexion was limited to 90 degrees with further flexion precluded by pain and stiffness. Even considering some further functional loss of flexion upon use based on pain in the joint, including upon exacerbations and flare-ups (as noted in the September 1998 VA examination) more than a 10 percent rating, equivalent to a limitation of flexion to 45 degrees, cannot be assigned on the basis of limitation of flexion in this case. When extension of a knee is limited to 10 degrees, a 10 percent rating is assigned; when limited to 15 degrees, a 20 percent rating is assigned; and when limited to 20 degrees, a 30 percent rating is assigned. Diagnostic Code 5261. Upon recent VA examination in December 1997, extension was limited to 5 degrees due to pain, and upon VA examination in September 1998, extension was limited to 10 degrees. Purely based on these numbers, only a 10 percent rating could be assigned based on limitation of extension to 10 degrees. Further extension deficits were not noted by examiners to be associated with pain and stiffness, though the veteran reported increased fatigability and weakness, and decreased range of motion with ongoing use. A knee disorder may also be rated on the basis of other impairment, including recurrent subluxation or lateral instability, under Diagnostic Code 5257. The Board herein considers a rating on this basis because the veteran has a long history of knee disability with surgical intervention. However, within the rating period, from December 2, 1993, to the present, VA examinations including in February 1995, June 1996, September 1997, and December 1997, noted no subluxation or lateral instability. In February 1995 there was no undue ligamentous laxity; in June 1996 there was only mild global laxity; in December 1997 there was no laxity; and in September 1998 there was no evidence of instability. Hence, despite the veteran's report at the June 1996 VA examination that his knee had previously given out, and despite his report at the December 1997 VA examination that there was instability in the left knee, there is insufficient medical evidence to support a separate disability rating under Diagnostic Code 5257, including on the basis of either subluxation or lateral instability. Regarding the record of the knee disorder generally, the Board notes that while the veteran reports continuous pain, he did not report and was not found upon examination to be incapable of regular ambulation due to the left knee. There is no report of the veteran using a crutch, cane or other assistive device, and also no report of the veteran using a knee brace. The veteran reports that he also has difficulties with his right knee and right ankle, which together with his left knee disorder have reportedly recently preclude continued work as a corrections officer, work which required being quite active. Taken as a whole, based on contentions and medical findings of pain and stiffness in the joint and incidences of flare- ups and exacerbations, with the veteran's reports of weakness, fatigability, and decreased range of motion, the Board considers that a 20 percent rating is warranted for limitation of extension equivalent to extension limitation to 15 degrees. Diagnostic Code 5261. However, while considering DeLuca and limitation of motion based on pain, stiffness, weakness, and fatigability affecting functional use of the joint, the Board finds that the veteran's left knee disorder is still not so severe as to warrant a higher rating of 30 percent based on an equivalence to either limitation of extension to 20 degrees, or limitation of flexion to 15 degrees. DeLuca; 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Codes 5260, 5261 (1999). Accordingly, the Board finds that the veteran has been appropriately assigned a 20 percent rating for his left knee disorder. The Board has reviewed the entire record and finds that the 20 percent rating already assigned for the left knee disorder reflects the most disabling this disorder has been since the veteran was discharged from service, which is the beginning of the appeal period. Thus, the Board concludes that a higher rating than the 20 percent assigned is not appropriate for the left knee disorder effective from December 2, 1993, and that staged ratings for this disorder are not warranted. Fenderson v. West, 12 Vet. App Vet. App. 119 (1999). In reaching its decision the Board has also considered two pertinent precedent opinions of the VA General Counsel: VAOGCPREC 23-97 (July 1, 1997) and VAOGCPREC 9-98 (August 14, 1998). The Board finds that separate compensable ratings are not warranted for the left knee disorder, because during the appeal period there was no evidence of at least slight recurrent subluxation or lateral instability of the knee joint. ORDER 1. Service connection for a respiratory disorder is denied as not well grounded. 2. Service connection for a skin disorder is denied as not well grounded. 3. Service connection for Lyme disease, including as due to undiagnosed illness, is denied as not well grounded. 4. Service connection for chronic fatigue, including as due to undiagnosed illness, is denied as not well grounded. 5. Entitlement to an increased rating above the 20 percent currently assigned for a left knee disorder is denied. BRUCE E. HYMAN Member, Board of Veterans' Appeals