Citation Nr: 0004485 Decision Date: 02/18/00 Archive Date: 02/23/00 DOCKET NO. 95-39 700 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for a chronic low back disability, asserted to be secondary to service-connected disabilities. 2. Entitlement to an increased evaluation for residuals of a right knee injury with scarring and instability, currently evaluated as 20 percent disabling. 3. Entitlement to an increased evaluation for residuals of a left knee injury with scarring and strain, currently evaluated as 10 percent disabling. 4. Entitlement to an increased evaluation for post-operative residuals of a fracture of the proximal right humerus with bicep weakness and atrophy, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. L. Wright, Counsel INTRODUCTION The veteran had active service from July 1978 to October 1982. This appeal arises from a July 1995 rating action of the Buffalo, New York, regional office (RO). In this decision, the RO denied service connection for a low back disability asserted to be secondary to service-connected disabilities and also denied increased evaluations for the veteran's service-connected right knee disability (evaluated as 20 percent disabling), a left knee disability (evaluated as noncompensably disabling), and a right arm disorder (evaluated as 10 percent disabling). These determinations were appealed by the veteran. In a rating decision of May 1997, the RO granted an increased evaluation to 10 percent for the veteran's left knee disorder. In November 1997, the Board of Veterans' Appeals (Board) remanded this case to the RO for further evidentiary development. On remand, the RO issued a supplemental statement of the case (SSOC) in May 1999 which noted the grant of an increased evaluation to 20 percent for the veteran's service-connected right arm disability. In August 1999, the RO returned the veteran's case to the Board. FINDINGS OF FACT 1. All evidence required for an equitable determination of the issues on appeal has been obtained. 2. No competent evidence has been received which associates any low back disability that the veteran may have (including any lumbosacral strain) to a service-connected disability. 3. The veteran's service-connected right knee disability is characterized by moderate instability, constant pain, swelling, and minimal limitation of motion even during flare- ups. He has not demonstrated easy fatigability or inconsistent efforts and has, in fact, been able to comply with all of the expressed exams "with good carry-through." 4. The veteran's service-connected left knee disability is characterized by slight instability, constant pain, swelling, and minimal limitation of motion even during flare-ups. He has not demonstrated easy fatigability or inconsistent efforts and has, in fact, been able to comply with all of the expressed exams "with good carry-through." 5. The medical evidence of record reflects minimal degenerative changes in both of the veteran's knees. 6. The veteran's service-connected right arm disability is characterized by constant pain, an inability to raise the arm above shoulder level during exacerbation of pain, moderate deformity of the humerus, moderate deformity of the affected musculature, and loss of sensation around the scars. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for a chronic low back disability, asserted to be secondary to service-connected disabilities is not well-grounded. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. § 3.310 (1999). 2. An increased evaluation in excess of 20 percent disabling is not warranted for the service-connected residuals of a right knee injury with scarring and instability. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.10, 4.14, 4.20, 4.40, 4.45, 4.68, 4.71, Codes 5162, 5256-5263 (1999). See also VAOPGCPREC 23-97 & 9-98. 3. An increased evaluation in excess of 10 percent disabling is not warranted for the service-connected residuals of a left knee injury with scarring and strain. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.10, 4.14, 4.20, 4.40, 4.45, 4.68, 4.71, Codes 5162, 5256-5263 (1999). See also VAOPGCPREC 23-97 & 9-98. 4. An increased evaluation to 10 percent disabling, but not more, is warranted for the veteran's minimal degenerative changes of both knee joints. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.10, 4.14, 4.20, 4.40, 4.45, 4.68, 4.71, Code 5003 (1999). See also VAOPGCPREC 23-97 & 9- 98. 5. An increased evaluation in excess of 20 percent disabling is not warranted for the service-connected post-operative residuals of a fracture of the proximal right humerus with bicep weakness and atrophy. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.10, 4.14, 4.20, 4.40, 4.45, 4.68, 4.71, Codes 5201, 5202, 5305 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background In March 1983, the veteran filed claims with the United States (U. S.) Department of Veterans Affairs (VA) for service connection for right arm and bilateral knee disabilities. Attached to this claim were part of the veteran's service medical records. These records did not include an entrance examination. A medical record of March 1981 indicated that the veteran had fallen from a 50 foot crane and sustained right arm, bilateral knee, and concussive injuries. An examination of May 1981 conducted for a U. S. Navy Medical Board noted diagnoses for fracture of the right humerus and healed lacerations of both knees. There were no abnormalities shown with regard to the veteran's back or spine. The veteran was released for six months limited duty. A second set of service medical records was received from the U. S. Navy in October 1983. Another physical examination was conducted for a Medical Board in September 1982. It was reported that since the last Medical Board proceeding, the veteran had undergone surgery to repair his right arm and subsequent physical therapy. The final diagnoses were a healed fracture of the right humerus and a ruptured posterior cruciate ligament in the right knee. There were no findings made regarding the veteran's back or spine. The veteran was afforded a series of VA physical examinations in October 1983. His complaints included pain in his lower hips and back. None of the examinations reported any abnormalities with the veteran's low back. By rating decision of February 1984, the RO granted service connection for residuals of a right knee injury with scarring and instability, residuals of a left knee injury with scarring and strain, residuals of a post-operative fracture of the proximal right humerus, and a donor site scar on the left iliac crest. It was reported by the RO that the iliac scar was the result of the veteran's in-service surgery for a donor bone graft from his iliac spine used to repair his right humerus. The veteran's right knee disability was evaluated as 20 percent disabling under the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4, Diagnostic Code (Code) 5257 effective from October 1982. His left knee and right arm disabilities were both evaluated as noncompensable under Codes 5257 and 5202, respectively, effective from October 1982. In November 1985, the veteran was provided VA orthopedic and neurological examinations. He did not complain of any low back disorders or symptoms on these examinations, nor did the examiners report any abnormalities with his low back. By rating decision of late November 1985, the RO confirmed and continued the veteran's disability evaluations. VA neurological and orthopedic examinations were again provided to the veteran in March 1988. The examination reports failed to note any abnormalities with the veteran's back. In a rating decision of May 1988, the RO continued and confirmed the veteran's service-connected evaluations, except for the evaluation of his right arm disability. This disorder's evaluation was increased to 10 percent disabling effective from January 1988 under Codes 5202 and 5305. The VA provided the veteran with neurological and orthopedic examinations in June 1990. He complained of low back pain. No findings or diagnosis was noted on the examination reports. By rating decision of September 1990, the RO confirmed and continued the veteran's previous disability evaluations. In September 1994, the veteran filed a claim for increased evaluations for his bilateral knee and right arm disabilities. He also filed a claim for service connection for his low back pain. The RO sent a letter to the veteran in December 1994 requesting that he submit evidence that his claimed low back disability was incurred in military service or aggravated by a service-connected disability. He was informed that his failure to submit this type of evidence could have an adverse effect on his claim. The veteran's VA outpatient records dated from September to November 1994 were associated with his claims file in December 1994. In September 1994, the veteran complained of back pain. He asserted that when he had fallen off a crane during his military service a waist safety line snapped and jerked him. The veteran alleged that his back pain had started at that point and had become progressively worse since then. He also complained of increased knee pain that was aggravated by prolonged standing, walking, and weight lifting. The impression was chronic pain. A series of VA radiological studies were conducted in September 1994. A bilateral knee X-ray revealed a left knee within normal limits. The right knee had calcification adjacent to the right medical femoral condyle that may represent an old medial collateral ligament injury. There was also very early evidence for osteophyte formation consistent with minimal degenerative change in the anteromedial area of the right medial tibial plateau. A lumbosacral X-ray was found to be unremarkable except for a deformity of the left iliac wing. The radiologist opined that this appeared to be old and could be post-traumatic or post-operative in origin. A VA outpatient examination of November 1994 found right knee laxity in the anterior cruciate ligament and the medial/lateral collateral ligament. The left knee had no laxity. There was full range of motion in both knees. The impressions were chronic low back and left knee pain, right knee laxity, and no signs of acute radiculopathy. By rating decision of July 1995, the RO denied service connection for a low back disability, asserted to be secondary to service-connected disabilities. It was determined that there was no medical evidence to establish a connection between the veteran's current low back disorder and his service-connected disabilities. The RO, therefore, determined that this service connection claim was not well- grounded. The RO also determined that increased evaluations were not warranted for the veteran's service-connected right arm and bilateral knee disabilities. The veteran timely appealed this decision. In a letter of September 1995, the RO requested that the veteran submit lay and medical evidence to corroborate his claim of increased severity in his service-connected disabilities. He was informed that his failure to submit this type of evidence could have an adverse effect on his claims. In his substantive appeal of October 1995, the veteran claimed that his service-connected left knee disability was of a severe nature. He alleged that if he squatted, his left knee disorder prevented him for standing up. It was contended that the arthritis noted on X-ray of his right knee entitled him compensation in excess of 20 percent disabling. The veteran claimed that his low back disability had been aggravated by his service-connected bilateral knee disabilities. He alleged that he had severe pain in his low back that radiated into his feet and that if he sat for more than 30 minutes his feet would go numb. VA outpatient records dated from September to November 1994 were associated with the claims file in March 1996. Most of these records were duplicates of records received in December 1994. However, an undated outpatient record reported that the veteran was only employed on a part-time basis due to his pain. On examination, the veteran's back was tender on the left trapezius and on the mid/lower paraspinal muscles. The veteran was reported to experience pain across his lower back with forward bending and lateral movement. There was laxity in the front and back of the right knee. No effusion, warmth, or erythema was found in either knee. Bilateral crepitus was noted in the knees. Straight leg raises were negative, motor strength was equal and within normal limits, and sensation was normal. Additional VA medical records dated from March to July 1996 were incorporated into the claims file in September 1996. A left knee X-ray of March 1996 found a small bony density anterior and superior to the patella. It opined that this finding may represent a small spur at the patellar tendon insertion, but no obvious arthritic changes were visualized. An outpatient record of July 1996 reported the veteran's complaint of feelings of constant instability in both knees. He claimed that his bilateral knee pain limited his ability to walk, stand, run, and participate in sports and activities he had previously enjoyed. The veteran acknowledged that he currently biked for exercise. He also claimed to experience back pain. On examination, there was no joint deformity or effusion. The veteran was positive for focal tenderness over the medical and lateral collateral ligaments in the right knee. However, there was no focal tenderness over the vertebral column and sacroiliac joint. Full range of motion was noted in both lower extremities, but there was joint laxity in the anterior/posterior and medial/lateral ligaments of both knees. There were no sensation deficits; motor strength was "4+" on a scale from one to five in the lower extremities; and reflexes were "2+", equal, and symmetrical. The impressions were unstable right knee and chronic low back pain. An outpatient record of June 1996 noted the veteran's claim that he had injured his back when he fell off a crane during his military service and again in a motorcycle accident earlier in June 1996. It was asserted that the private hospital that X-rayed his low back after the motorcycle accident found nothing wrong with his lumbar spine except an old "wedge" fracture. The veteran claimed that he had experienced intermittent back problems since his crane accident in the military. The impression was lumbosacral strain and to rule out herniated nucleus pulposus. The veteran was afforded a series of VA examinations in November 1996. The VA orthopedic examination noted that the veteran was right-handed. He complained of limitation of motion in his right arm and problems with his knees during changes in the weather. On examination, the veteran's gait was normal. The scars on the right arm were well-healed and non-tender. He had full range of motion in the right arm, except for hyperabduction which could not be accomplished for the last 25 degrees of movement. The strength in the veteran's right arm was characterized as "good." There was a superficial scar on each patellar area measuring about 1 and 1/2 inches in length and 1/16 inch in width. The left knee had instability in the lateral medial axis. While the veteran claimed to have instability in the right knee, the examiner believed that this was only movement of the veteran's calf muscle not the underlying joint itself. The veteran was able to do a full deep knee squat and there was full motion in both knees on passive motion. There was no evidence of swelling in either knee. The impression was weakness in the left knee's collateral ligaments and/or involvement of the underlying menisci, which the examiner requested be confirmed by magnetic resonance imaging (MRI). It was opined by the examiner that "while the history of the injuries sustained as a result of a fall from a height of 50 feet is quite credible, I do have the impression that [the veteran] tends to exaggerate some of his complaints referable to his musculoskeletal system." A series of radiological studies was conducted in connection with this examination. The lumbar spine X-ray revealed no abnormalities except for a bony defect of the left iliac wing. The radiologist opined that this abnormality was probably the result of a previous bone graft donor site or old trauma. X-rays of the right shoulder found no abnormalities in this joint, but a large callous formation with several bony fragments around the site where found at the right mid-humerus. An X-ray of the right knee found no abnormality. The VA neurological examination of November 1996 reported that the veteran had a compound dislocation of his fifth digit in his right hand. It was noted by the veteran that this injury had made it difficult to close the right hand. On examination, there was normal strength in all extremities except for the right hand fifth finger extensors and flexors. The physician attributed this abnormality to the veteran's compound fracture sustained in 1996. Deep tendon and sensation was symmetrical in upper and lower extremities. Testing of the veteran's gait showed that he could walk on his heels, toes, and in tandem forward and backward. The impression was post-traumatic headaches. In a supplemental statement of the case (SSOC) issued to the veteran in May 1997, the veteran was informed that the evaluations of his service-connected right knee and right arm disorders were confirmed and continued. However, his left knee disability received an increased evaluation to 10 percent disabling under Code 5257 effective from September 1994. The RO again denied secondary service connection for the veteran's claimed low back disability. It was determined by the RO that a low back disability had not been diagnosed or associated with his service-connected disabilities. The veteran submitted private medical records dated in June 1996 to the RO in August 1997. These records noted treatment of the veteran's low back after he had fallen off of a motorcycle. He complained of left flank, pelvis, and back pain. On examination, there was palpable tenderness along the midline of the lumbosacral spine. Straight leg raises were negative. A lumbosacral spine X-ray noted no compression fracture or disc space narrowing. The diagnosis was back spasm due to a fall with no fracture. Another SSOC was issued to the veteran in September 1997 in which he was informed that his claim for secondary service connection for a low back disability was not well-grounded. In November 1997, the Board remanded this case to the RO for development of the medical evidence. The RO issued a letter to the veteran in February 1998. In this letter the veteran was requested to identify all healthcare providers that had treated his service-connected disabilities. He was also requested to submit private treatment records for his claimed low back disability. The veteran was informed that his failure to provide this evidence could have an adverse effect on this claims. Also in February 1998, the RO requested the veteran's treatment records from the Albany, New York, VA Medical Center (VAMC). The Albany VAMC responded later that same month that there were no treatment records for the veteran at its location. The veteran was provided with a VA orthopedic examination in August 1998. He claimed that he could not lift his right arm over his head or lift heavy weights. The veteran also claimed that his right arm pain had become slightly worse in recent years. It was alleged by the veteran that he had decreased sensation and tingling around the scar on his right arm. The physician noted that the veteran's dominant extremity was his right hand and affected his ability to do higher levels of daily activity. The veteran complained of laxity in his right knee that his treating physician had recommend surgery to repair. He reported that he took pain medication for this problem and wore a knee brace. The veteran complained of chronic pain in his left knee that was worse with climbing stairs. An examination of the right arm revealed three scars; the first was located on the upper shoulder and was horizontal with a length of one centimeter (cm), the second was located below the first and was eight cm long, and the third was vertically below the second scar and was 16 cm long. The diameter of the right bicep was 29.5 cm and the left was 31 cm. Sensory and strength testing was grossly normal, except for the area around the vertical scar. The range of motion in the right arm was limited to shoulder level or approximately 100 degrees. There was pain on palpation of the posterior musculature, except along the medial aspect of the scapula. The right knee showed a horizontal scar approximately six cm long. There was no obvious swelling. Range of motion testing noted hyperextension of five degrees to flexion of approximately 100 degrees. There was gross instability in both the anterior and posterior directions, and some medial and lateral instability. The left knee had two scars, the first was horizontal and approximately two cm long, while the second was a horizontal scar below the first and was six and a half cm long. Range of motion in the left knee was from a neutral position to 100 degrees flexion. There was approximately "1+" instability to anterior drawer sign. Pain was noted on instability testing and over the medial collateral ligament. The impressions of the August 1998 examination included status post accident with right humerus fracture with scars and bicep atrophy, right knee injury with laceration and gross instability (anterior and posterior, medially and laterally), and left knee injury with mild anterior instability and pain over the medial collateral ligament consistent with a possible mild medial collateral or meniscal injury. The examiner noted that the veteran's claims file had not been available for review and that an MRI of the veteran's left knee was recommended. Finally, the examiner opined that: Any weakened motion, incoordination, fatigability is noted in the exam, but these factors cannot be further quantified in terms of additional loss of range of motion without prolonged provocative testing which is not practical at this time. With flare-ups, it is likely range of motion would be further restricted, but it is not possible to actually estimate the additional loss of range of motion without examining the patient at the time of the flare-up. A left knee MRI was provided to the veteran in September 1998. The noted abnormalities included some mild degeneration in the posterior horn of the medial meniscus. There also appeared to be a split of some of the fibers of the anterior cruciate ligament which was compatible with a sprain or partial tear of the anterior cruciate ligament versus an old anterior cruciate ligament injury with some mild edema. There was a minimal amount of joint fluid present. Another VA orthopedic examination was given to the veteran in April 1999. In the report, the examiner noted that the veteran's claims file had been available for review. It was determined that the veteran was right-handed and was employed "running machines." He claimed that he was injured during his military service and had received only one subsequent injury since that time which consisted of his motorcycle accident in 1996. The veteran complained of constant pain in his lumbar spine. He claimed that the intensity of this pain on a scale from one to ten felt to be at a level of five. The veteran asserted that his back pain was exacerbated by heavy activity and would rise to a pain level of seven. During periods of exacerbation, his low back pain radiated down his left leg to his ankle. He also claimed that if he sat for a prolonged period of time he would experience numbness in his ankles. The veteran also described constant pain in his knees. He alleged that the level of this pain in the left knee was at a level of seven and in the right knee at a level of five. During periods of exacerbation, the veteran asserted that his bilateral knee pain increased to a level of nine. It was claimed by the veteran that any significant activity would exacerbate his knee pain, including walking up three flights of stairs to his apartment. The veteran alleged that his left knee also had clicking, popping, swelling, but denied any instability in this knee. He asserted that his right knee bothered him with any sports activity and that it was unstable requiring the use of a brace for extended activities. The veteran alleged that when his right knee gave way it would cause significant swelling. It was claimed by the veteran that this bilateral knee disability interfered with him doing any type of prolonged activity, climbing stairs, or kneeling. He alleged that his joint pain interfered with his sleep and his ability to conduct gainful employment. The veteran asserted that his right shoulder made overhead work difficult. He claimed that his right shoulder would pop, click, grind, and have significant pain. It was allege by the veteran that this pain was at a level of six, and during exacerbations rise to a level of eight. The veteran noted that his right arm was weaker than his left arm. On examination of the veteran's upper right extremity, he had three scars that were all well-healed with no erythema or sign of breakdown. However, there was numbness along these scars. Sensory examination also revealed numbness along the anterolateral aspect of the right forearm that was consist with the lateral brachial cutaneous sensory nerve. There was also obvious sign of right bicep rupture with the bicep muscle bulging up in the proximal antecubital area. Motor strength in the right upper extremity was four on a scale from one to five, while the left upper extremity showed strength of five out of five. Right hand grip and wrist strength was also five out of five. There was atrophy in the right bicep. The veteran was positive for pain on extreme abduction and to palpation over the acromioclavicular joint and subacromial region. Crepitus was also noted in the glenohumeral joint during motion. The range of motion in the right arm measured 160 degrees forward flexion, 20 degrees extension, 160 degrees abduction, and internal and external rotation to 60 degrees. A right arm X-ray noted a healed mid-shaft fracture of the right humerus. The radiologist reported that the humerus had healed without evident complication. The examination of the veteran's knees revealed well-healed scars with no erythema. There was a trace of swelling in both knees. Crepitus was noted in both patellae. Pain was elicited on active contraction of the quadriceps while distracting the patella. There was also bilateral atrophy at the vastus medalis oblique. Range of motion testing revealed the right knee went from five degrees of hyperextension to 110 degrees of flexion, while the left knee went from zero degrees extension to 120 degrees flexion. Regarding the veteran's instability, neither knee showed laxity to medial collateral ligament or lateral collateral ligament. However, the right knee had gross laxity to posterior cruciate ligament and anterior cruciate ligament, while the left had laxity to the anterior cruciate ligament. There was bilateral pain to palpation along the joint line and patella border. The veteran was able to sustain a squat and then stand without assistance. Bilateral knee X-rays were reported to be negative. On examination of the lumbar spine, the only abnormality reported was pain to palpation at the thoracolumbar junction, at the L4-L5 level, and at the L5-S1 level. Range of motion in the lumbar spine was 90 degrees forward flexion, 30 degrees backward extension, 40 degrees of bilateral side bending, and 45 degrees of bilateral rotation. A lumbosacral X-ray noted some surgical deformity of the left ileum as described in previous X-rays; otherwise, the current X-ray was found to be negative. The impressions on the April 1999 examination included bilateral chondromalacia patella; status post right knee traumatic injury with laceration, scars, and laxity of the anterior cruciate ligament and posterior cruciate ligament; a history of laceration injury to the left knee with scars, mild anterior instability, and pain over the joint line; chronic low back pain with sensory loss; and status post fracture of the right humerus with a bicep tear and atrophy, sensory loss in the lateral brachial cutaneous, and signs of right shoulder impingement syndrome. The examiner noted the veteran's claim that his private lumbosacral X-rays of June 1996 had revealed an old wedge fracture. It was reported by the examiner that copies of these X-ray reports contained in the claims file failed to note such a fracture and expressed the opinion that the actual X-rays be obtained to be reviewed by a VA radiologist to determine if they actually showed a wedge fracture. Finally, the examiner noted the following: During this exam the veteran demonstrated consistent effort in all of his physical exams. He did not demonstrate easy fatigability or inconsistent effort. He was able to comply with all of the expressed exams with good carry- through...Any weakened motion, incoordination, or fatigability is noted in the exam, but these factors cannot be further quantified in terms of additional loss of range of motion without prolonged provocative testing. With flare-ups, it is likely range of motion would be further restricted. It is not possible to accurately estimate the additional loss of range of motion without examining the patient at that time. The veteran was issued a SSOC in May 1999. He was informed that the RO had again determined that his claim for secondary service connection for a low back disability was not well- grounded. The evaluations for his service-connected left and right knee were confirmed and continued. However, the RO did grant an increased evaluation for the veteran's service- connected right arm disability to 20 percent disabling under Code 5305 and 5201 effective from September 1994. II. Secondary Service Connection for a Low Back Disability a. Applicable Criteria Service connection may be granted for disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of a pre-existing injury suffered, or disease contracted, in the line of duty. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). Where a veteran served ninety days or more during a period of war or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of ten percent or more within one year of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991 and Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). This presumption is rebuttable by affirmative evidence to the contrary. Id. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). A disability which is proximately due to, or the result of, a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (1999). When aggravation of a nonservice- connected disability is proximately due to, or the result of, a service-connected disability, the additional degree disability over and above the degree of pre-existing disability prior to the aggravation shall be service- connected. Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order for a claim to be well grounded, there must be competent evidence of a current disability in the form of a medical diagnosis, of incurrence or aggravation of a disease or injury in service in the form of lay or medical evidence, and of a nexus between the in-service injury or disease and the current disability in the form of medical evidence. Caluza v. Brown, 7 Vet. App. 498 (1995). Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307 (1999) as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (1999). This rule does not mean that any manifestation in service will permit service connection. To show 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required where the condition noted during service or in the presumptive period is not shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the condition noted during service is not shown to be chronic or the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The regulation requires continuity of symptomatology, not continuity of treatment. Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). The United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, "the Court") has established the following rules with regard to claims addressing the issue of chronicity. The chronicity provision of 38 C.F.R. § 3.303(b) is applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded if (1) the condition is observed during service, (2) continuity of symptomatology is demonstrated thereafter and (3) competent evidence relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 489 (1997). A lay person is competent to testify only as to observable symptoms. See Savage; Falzone v. Brown, 8 Vet. App. 398, 403 (1995). A lay person is not, however, competent to provide evidence that the observable symptoms are manifestations of chronic pathology or diagnosed disability. Id. Where the determinant issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Although the veteran is competent to testify as to his in-service experiences and symptoms, where the determinative issue involves a question of medical diagnosis or causation, only individuals possessing specialized medical training and knowledge are competent to render such an opinion. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Lay assertions of medical causation will not suffice initially to establish a plausible, well- grounded claim, under 38 U.S.C.A. § 5107(a). Grottveit v. Brown, 5 Vet. App. 91(1993). b. Analysis As noted above, the veteran is currently service-connected for bilateral knee and right arm disabilities. He is also service-connected for a donor site scar on the left iliac crest from his in-service surgery. The veteran has specifically claimed that his bilateral knee disability has either caused or permanently aggravated a low back disability. He therefore contends that this low back disability should be service-connected under 38 C.F.R. § 3.310(a). As the veteran is a lay person, he is not competent to provide an opinion on either a diagnosis or etiology of a disorder. Only a competent medical professional can provide such an opinion. See Zang v. Brown, 8 Vet. App. 246 (1995). The evidence indicates that the veteran first complained about low back pain almost exactly one year after his separation from the military. However, the examiner in October 1983 failed to note a diagnosis for a low back disorder. Most of the impressions of record regarding the veteran's low back complaints have been for chronic pain and have not included diagnoses of an underlying condition that could cause this pain. The veteran did received diagnoses for a lumbosacral strain and a back spasm in June 1996. However, both of these disorders were associated with a motorcycle accident that took place in the same month. All later examinations failed to note impressions for a low back strain. The veteran has claimed that radiological studies taken in June 1996 after his motorcycle accident revealed an old wedge fracture in his lumbar spine. He has claimed that this fracture was the result of his in-service injury. However, the private X-ray reports of June 1996 specifically reported no findings of fracture in the lumbar spine. The only abnormality found in the veteran's lumbar spine has been a surgical deformity of the left ileum. This residual is already service-connected under Code 7805 as the donor site for the veteran's in-service surgery, and, in any event, there is no medical opinion of record that has associated the veteran's complaints of low back pain to this minor abnormality. The VA examiner of April 1999 opined that the original films of the private June 1996 lumbosacral X-rays should be obtained for review by a VA radiologist in order to rule out the existence of a compressed fracture. Such action is not warranted in the present case. The existence of a compression fracture in the veteran's lumbar spine is based solely on a history as given by the veteran. Such an uncorroborated lay history does not have to be accepted by the VA. See Gilbert v. Derwinski, 1 Vet. App. 49 (1991). The April 1999 examiner acknowledged that the private X-ray report of June 1996 failed to disclose a compression fracture. A review of the veteran's service medical records notes the obvious source of the iliac spine abnormality as the donor site for the veteran's in-service surgery and not a compression fracture. The only diagnosed low back disability, a lumbar strain, has been associated by competent medical opinion to the veteran's post-service motorcycle accident in June 1996. All other examinations regarding the veteran's complaints of low back pain have failed to determine a medical etiology for these complaints. There is no competent medical opinion of record that has associated any low back disability that the veteran may have (which is manifested by complaints of pain) with any of his service-connected disabilities. Thus, there is no basis for a finding of a well-grounded claim for secondary service connection under the provisions of 38 C.F.R. § 3.310(a) or the Allen decision. There is no medical evidence linking any low back disability that the veteran may have (which is manifested by pain and by the June 1996 finding of lumbosacral strain) to his service- connected disorders. Without a medical opinion indicating such a nexus, the veteran's claim is not well-grounded under either the Caluza or Savage tests. He was specifically informed in a letters of September 1994 and February 1998, subsequent SSOC's, and the Board's remand of November 1997 that in order to make his claim well-grounded he needed a medical nexus opinion. Therefore, the VA has met is duty to inform the veteran of the requirements for the submission of a well-grounded claim. See Robinette v. Brown, 8 Vet. App. 69 (1995). There is no duty to assist under the provisions of 38 U.S.C.A. § 5107(a) (West 1991) in a claim that is not well-grounded. See Grottveit v. Brown, 5 Vet. App. 91 (1993). Therefore, based on the above analysis, service connection for a low back disability, asserted to be secondary to service-connected disabilities, is denied. III. Increased Evaluations for Bilateral Knee Disabilities a. Applicable Criteria Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). 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 conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. §§ 4.1 and 4.2 (1999). Also, 38 C.F.R. § 4.10 (1999) provides that, in cases of functional impairment, evaluations must be based upon lack of usefulness of the affected part or systems, and medical examiners must furnish, in addition to the etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, full description of the effects of the disability upon the person's ordinary activity. These requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based upon a single, incomplete, or inaccurate report, and to enable the VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath, 1 Vet. App. at 594. In addition, 38 C.F.R. § 4.40 (1999) requires consideration of functional disability due to pain and weakness. As regards the joints, 38 C.F.R. § 4.45 (1999) notes that the factors of disability reside in reductions of their normal excursion of movements in different planes. The considerations include more or less movement than normal, weakened movement, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, swelling, deformity or atrophy of disuse, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. With any form of arthritis, painful motion is an important factor of the rated disability and should be carefully noted. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or mal-aligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. 38 C.F.R. § 4.59 (1999). The evaluation of the same disability or manifestations under different diagnoses is to be avoided. 38 C.F.R. § 4.14 (1999). Rather, the veteran's disability will be rated under the diagnostic code which allows the highest possible evaluation for the clinical findings shown on objective examination. However, 38 C.F.R. § 4.14 does not prevent separate evaluations for the same anatomic area under different diagnostic codes that evaluate different symptomatology. Esteban v. Brown, 6 Vet. App. 259 (1994). Based upon the principle set forth in Esteban, the VA General Counsel (GC) held that a knee disability may receive separate ratings under diagnostic codes evaluating instability (Code 5257, 5262, and 5263) and those evaluating range of motion (Codes 5003, 5256, 5260, and 5261). See VAOPGCPREC 23-97. The applicable schedular criteria are as follows: Code 5003. Arthritis, degenerative (hypertrophic or osteoarthritis): Degenerative arthritis established by X- ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 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, 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 the absence of limitation of motion, rate as below: >With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations; rate as 20 percent disabling. >With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups; rate as 10 percent disabling. * Note (1): The percentage ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Code 5256. Knee, ankylosis of: >Favorable angle in full extension, or in slight flexion between 0° and 10°; rate as 30 percent disabling. Code 5257. Knee, other impairment of: >Recurrent subluxation or lateral instability: Severe; rate as 30 percent disabling. Moderate; rate as 20 percent disabling. Slight; rate as 10 percent disabling. Code 5258. Cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint; rate as 20 percent disabling. Code 5259. Cartilage, semilunar, removal of, symptomatic; rate as 10 percent disabling. Code 5260. Leg, limitation of flexion of: >Flexion limited to 15°; rate as 30 percent disabling. >Flexion limited to 30°; rate as 20 percent disabling. >Flexion limited to 45°; rate as 10 percent disabling. >Flexion limited to 60°; rate as noncompensable. Code 5261. Leg, limitation of extension of: >Extension limited to 45°; rate as 50 percent disabling. >Extension limited to 30°; rate as 40 percent disabling. >Extension limited to 20°; rate as 30 percent disabling. >Extension limited to 15°; rate as 20 percent disabling. >Extension limited to 10°; rate as 10 percent disabling. >Extension limited to 5°; rate as noncompensable. Code 5262. Tibia and fibula, impairment of: >Nonunion of, with loose motion, requiring brace; rate as 40 percent disabling. >Malunion of: With marked knee or ankle disability; rate as 30 percent disabling. Code 5263. Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) rate as 10 percent disabling. 38 C.F.R. Part 4 (1999). Normal range of motion in a knee joint is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (1999). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (1999). The combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. 38 C.F.R. § 4.68 (1999). b. Analysis The first responsibility of a claimant is to present a well- grounded claim. 38 U.S.C.A. § 5107(a) (West 1991). A claim for an increased evaluation is well-grounded if the claimant asserts that a disorder for which service connection has been granted has worsened. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). In this case, the veteran asserted that his knee disabilities are worse than evaluated, and he has thus stated a well-grounded claim. In addition, the undersigned finds that the VA has conducted all development required in this case to comport with the requirements of 38 U.S.C.A. § 5107(a). The Board's remand of November 1997 required that the RO request information from the veteran on his healthcare providers, request treatment records from the Albany, New York, VAMC, and conduct a thorough compensation examination based on the veteran's entire medical history. These actions were carried out by the RO and do not require any further development. See Stegall v. West, 11 Vet. App. 268 (1998). It is also found that the veteran has been adequately informed of the requirements for increased evaluations of his bilateral knee disabilities in the RO's letter of September 1995, the Board's remand of November 1997, and the statement of the case and SSOC's of recent years. As the veteran has been provided with the opportunity to present evidence and arguments on his behalf and availed himself of those opportunities, appellate review is appropriate at this time. See Robinette v. Brown, 8 Vet. App. 65 (1995); Bernard v. Brown, 4 Vet. App. 384 (1993). In accordance with the GC's opinion noted above, a veteran who evidences symptoms of restricted range of motion and instability in a knee joint with a service-connected disability can receive separate evaluations on the same joint. See VAOPGCPREC 23-17. The RO has rated the veteran's knee disabilities under Code 5257 based on instability, and not on restricted range of motion, based in part on the provisions of 38 C.F.R. § 4.14. However, in light of the Court's decision in Esteban and the GC's opinions, the veteran is entitled to such an evaluation. Initially, the undersigned must determine which rating criteria are related to restricted motion and which are related to instability in a knee joint. Obviously, Codes 5003, 5256, 5260, and 5261 evaluate limitation of motion in the knee. The criteria at Codes 5257, 5262, and 5263 variously discuss subluxation, instability, weakness, and loose motion. It is therefore apparent that these Codes evaluate instability in a knee joint. The GC itself commented on Codes 5258 and 5259 in an opinion of April 1998. It was noted that removal of the semilunar (meniscus) cartilage was done in order to resolve restriction of motion. Thus, Codes 5258 and 5259 encompass evaluation of the knee joint's restricted motion. See VAOPGCPREC 9-98. Concerning the evaluation of instability in the veteran's knees, he is currently evaluated as 20 percent disabled for his right knee instability and 10 percent disabled for his left knee instability under Code 5257. Any evaluation under Code 5262 requires malunion or nonunion of the tibia and fibula. There is no evidence of record that the veteran's service-connected knee disabilities have resulted in such a problem and, thus, an evaluation under Code 5262 is not warranted. It is also noted that the veteran's right knee has never been found to evidence genu recurvatum. He is, therefore, not entitled to an evaluation under Code 5263. Evaluating the instability in the veteran's knees, the evidence indicates that the veteran has gross instability in the right knee in posterior, anterior, medial, and lateral directions. In August 1998, his left knee instability was characterized as "1+." This instability has forced the veteran to use a brace and curtail his physical activities. It also appears that the right knee instability has resulted in the knee joint having five degrees of hyperextension. There is bilateral knee pain and swelling. While the veteran has claimed that his knee disorders have interfered with his employment, he acknowledged in April 1999 that he is currently employed. He also reported that he is able to use a bicycle and stationary bike for exercise. On examination in April 1999, the veteran was able to squat and stand up without assistance. This evidence indicates that increased evaluations for the instability in his knees is not warranted. The right knee is worse than the left, and the corresponding evaluations of moderate and slight instability appear appropriate. It has been acknowledged by the veteran that he is still able to do low impact exercise like biking and maintain his employment. While the veteran has made claims of significant levels of constant pain in his knees, the examiner of November 1996 found that the veteran tended to exaggerate his symptomatology. Under these circumstances, an increased evaluation for instability in either knee is not warranted. Turning to the veteran's restricted motion in his knees, the Board notes that the range of motion studies taken since the veteran filed his claim for an increased evaluation have failed to note limitation that would be compensable under either Codes 5260 or 5261. The veteran has claimed that any type of strenuous activity will exacerbate his pain resulting in difficulties with everyday activities like climbing stairs. He has never claimed that this pain has resulted in fixation or ankylosis of his knee joints. In August 1998 and April 1999, the examiners noted that any weakened motion, incoordination, or fatigability had been quantified on their examination reports. It was acknowledged by the examiners that flare-ups of symptomatology would result in additional restriction of motion in the knees, but found it impossible to quantify the additional restriction. Considering that the range of motion studies of record are not even close to a compensable level, that the veteran has not claimed significant limitation of motion even during flare-ups, and that the veteran was found at the April 1999 examination not to have demonstrated easy fatigability or inconsistent effort, the undersigned finds that a compensable evaluation under Codes 5260 and 5261 is not warranted. See also DeLuca v. Brown, 8 Vet.App. 202 (1995). This finding is also reinforced by the November 1996 examiner's opinion that the veteran exaggerated his symptoms, that the veteran is able on a consistent basis to exercise with biking, and that he maintains employment operating machinery. Furthermore, as the evidence of record does not indicate dislocation or removal of knee cartilage, compensable evaluations under Codes 5258 and 5259 is also not warranted. Finally, the radiological evidence has been inconsistent regarding degenerative changes in the knee joints. A right knee X-ray of September 1994 found osteophyte formation consistent with minimal degenerative changes and a left knee X-ray of March 1996 found small bony densities and a spur. The examiner of April 1999 opined that a review of the radiological evidence and clinical findings indicated degenerative changes were present in the right knee. Other radiological studies of record have found normal knee joints. Applying the provisions of 38 U.S.C.A. § 5107(b), the undersigned concedes that minimal degenerative changes exist in both of the veteran's knees. However, as noted in the previous paragraph, a compensable evaluation is not warranted under the appropriate diagnostic codes assessing limitation of motion in the knees. Therefore, based on the provisions of Code 5003, the veteran is entitled to a 10 percent evaluation for bilateral minimal degenerative changes in his knees. See 38 C.F.R. § 4.71a, Code 5003 (stipulating that, when 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, not added under Code 5003). A 20 percent evaluation under Code 5003 cannot be awarded, as these minimal degenerative changes have not resulted in incapacitating episodes. Id. As noted above, the veteran has maintained his employment, can do low impact exercises, and has not presented evidence of repeated medical treatment or bedrest for such incapacitating episodes. Furthermore, the examiner conducting the April 1999 examination specifically stated that the veteran did not, on evaluation, demonstrate easy fatigability or inconsistent efforts. He was, in fact, able to comply with all of the expressed exams "with good carry-through." All of the veteran's most recent examinations have reported that his knee scars are well-healed and he has not made any complaints regarding these scars. These scars do not require a separate evaluation under the appropriate diagnostic code as they are asymptomatic and the rating criteria for scars include pain and interference with motion of the adjacent joint. The latter criteria were considered in evaluating the veteran's knees in the above analysis and, thus, a separate evaluation would be prohibited under 38 C.F.R. § 3.14. See also 38 C.F.R. § 4.118, Codes 7803-7805 (1999). Based on the above analysis, the Board concludes that the veteran's right knee disability is characterized by moderate instability, constant pain, swelling, and minimal limitation of motion even during flare-ups. The left knee disability is characterized by slight instability, constant pain, swelling, and minimal limitation of motion even during flare-ups. He has not demonstrated easy fatigability or inconsistent efforts and has, in fact, been able to comply with all of the expressed exams "with good carry-through." This degree of symptomatology is entitled to a 20 percent evaluation for the right knee and a 10 percent for the left knee under Code 5257. However, as each knee evidences minimal degenerative changes without a compensable limitation of motion, the veteran is entitled to an additional 10 percent evaluation under Code 5003. See also DeLuca v. Brown, 8 Vet.App. 202 (1995). IV. Increased Evaluation for a Right Arm Disability a. Applicable Criteria The applicable rating criteria for the veteran's right arm disability includes the following: Code 5201. Arm, limitation of motion of: >To 25 degrees from side; rate as 40 percent disabling for the major extremity. >Midway between side and shoulder level; rate as 30 percent disabling for the major extremity. >At shoulder level; rate as 20 percent disabling for the major extremity. Code 5202. Humerus, other impairment of: >Loss of head of (flail shoulder); rate as 80 percent disabling for the major extremity. >Nonunion of (false flail joint); rate as 60 percent disabling for the major extremity. >Fibrous union of; rate as 50 percent disabling for the major extremity. >Recurrent dislocation of at scapulohumeral joint: -With frequent episodes and guarding of all arm movements; rate as 30 percent disabling for the major extremity. -With infrequent episodes, and guarding of movement only at shoulder level; rate as 20 percent disabling for the major extremity. >Malunion of: -Marked deformity; rate as 30 percent disabling for the major extremity. -Moderate deformity; rate as 20 percent disabling for the major extremity. Code 5305. Muscle Group V. Function: Elbow supination (1) (long head of biceps is stabilizer of shoulder joint); flexion of elbow (1, 2, 3). Flexor muscles of elbow: (1) Biceps; (2) brachialis; (3) brachioradialis. >Severe; rate as 40 percent disabling for a major extremity. >Moderately Severe; rate as 30 percent disabling for a major extremity. >Moderate; rate as 10 percent disabling for the major extremity. >Slight; rate as noncompensable. 38 C.F.R. Part 4 (1999). Normal range of motion in the shoulder joint is 0 to 180 degrees forward flexion, 0 to 180 degrees abduction, and internal and external rotation from 0 to 90 degrees in each direction. 38 C.F.R. § 4.71, Plate I (1999). b. Analysis The first responsibility of a claimant is to present a well- grounded claim. 38 U.S.C.A. § 5107(a) (West 1991). A claim for an increased evaluation is well-grounded if the claimant asserts that a disorder for which service connection has been granted has worsened. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). In this case, the veteran asserted that his service-connected right arm disability is worse than evaluated, and he has thus stated a well-grounded claim. In addition, the undersigned finds that the VA has conducted all development required in this case to comport with the requirements of 38 U.S.C.A. § 5107(a). This includes the RO's compliance with the Board's remand of November 1997 and providing the veteran with the opportunity to present evidence and arguments on his own behalf. See Stegall v. West, 11 Vet. App. 268 (1998); Bernard v. Brown, 4 Vet. App. 384 (1993). The veteran has claimed that his right arm disability has resulted in limitation of shoulder motion, right arm weakness, constant pain that increases during exacerbations, and an inability to do overhead work. A review of the objective medical evidence indicates that the veteran's right arm is his major extremity. There is also objective evidence of pain on extreme abduction and to palpation of the musculature. Strength in the right arm is only slightly less than normal and was reported as four on a scale of one to five in April 1999. Atrophy in the right bicep was measured in August 1998 as slight with one and a half cm less circumference with compared to the left bicep. Flexion and abduction of the right arm was measured, at its worst, in August 1998 when it was limited to approximately 100 degrees or shoulder level. In April 1999, the veteran's internal and external rotation was measured at 60 degrees. There was also neurological involvement with lack of sensation and tingling at the scar sites. Radiological studies have noted a healed mid-shaft fracture of the humerus without evidence complication. Finally, the examination of November 1996 found weakness in the fifth digit of the right hand as a residual of a compound fracture. Both the veteran and the examiner related this latter symptomatology to a post-service injury. Applying the rating criteria, the Board notes that the veteran is currently evaluated as 20 percent disabled due to his right arm disability. A higher evaluation is not warranted under Code 5201 as range of motion in the right arm, at its worst in recent years, still allows the veteran to raise the extremity to shoulder level. During the last VA examination of April 1999, the veteran was able to raise his arm significantly higher than shoulder level (e.g., to 160 degrees). It is noted that the examiners of August 1998 and April 1999 explained that any weakened motion, incoordination, or fatigability had been quantified on their examination reports. It was acknowledged by the examiners that flare-ups of symptomatology would result in additional restriction of motion in the right arm, but found it impossible to quantify the additional restriction. Since there is objective findings in recent years from full range of motion in the right arm to limitation of 100 degrees, it appears that the August 1998 examination was able to measure this limitation during a period of exacerbation. Also, pain on motion was only objectively found on extreme abduction. Moreover, at the April 1999 examination, the examiner specifically stated that the veteran did not demonstrate easy fatigability or inconsistent efforts and was, in fact, able to comply with all of the expressed exams "with good carry-through." Considering these facts and the November 1996 examiner's opinion that the veteran tended to exaggerate his symptomatology, the undersigned finds that the August 1998 range of motion accurately depicts the most severe limitation in this arm. This also is corroborated in the veteran's own statements that have asserted that he cannot raise his arm above shoulder level. There is no lay or objective evidence of nonunion, fibrous union, or recurrent dislocation in the right arm or shoulder. The X-ray's of record have only noted a healed humerus fracture with no other complications. This type of residual only rises to the level of a moderate deformity of the humerus and would not warrant an increased evaluation under Code 5202. Although there is evidence of sensory deficits around the scars, slight atrophy of the right bicep, and slight loss of strength in the right arm, this symptomatology could only be characterized as moderate in degree and would not warrant an evaluation in excess of 20 percent disabling under Code 5305. All of the veteran's most recent examinations have reported that his right arm and shoulder scars are well-healed; however, some sensory deficits do exist and are characterized by loss of sensation and tingling. These symptoms do not require a separate evaluation as the rating criteria for scars includes pain and interference with motion of the adjacent joint. See 38 C.F.R. § 4.118, Codes 7803-7805. The latter criteria were considered in evaluating the veteran's right arm disability in the above analysis and, thus, a separate evaluation would be prohibited under 38 C.F.R. § 3.14. Based on the above analysis, the veteran's right arm disability is characterized by constant pain, inability to raise the arm above shoulder level during exacerbations of pain, moderate deformity of the humerus, moderate deformity of the affected musculature, and loss of sensation around the scars. This degree of symptomatology is entitled to no more than a 20 percent evaluation under the applicable criteria. The Board acknowledges the veteran's complaints of right shoulder pain. Significantly, however, in view of the recent medical findings of only slightly less than normal strength in the right arm and only slight atrophy in the right bicep, as well as the April 1999 VA examiner's findings that the veteran did not demonstrate easy fatigability or inconsistent efforts and was, in fact, able to comply with all of the expressed exams "with good carry-through," the Board concludes that an increased rating for the veteran's service-connected right shoulder disability based upon any functional impairment he may experience in this joint due to pain on use, etc. cannot be awarded. See 38 C.F.R. § 4.40 and DeLuca v. Brown, 8 Vet.App. 202 (1995). ORDER Evidence of a well-grounded claim not having been submitted with respect to the issue of secondary service connection for a low back disability, this appeal is denied. An increased evaluation in excess of 20 percent disabling for residuals of a right knee injury with scarring and instability is denied. An increased evaluation in excess of 10 percent disabling for residuals of a left knee injury with scarring and strain is denied. A rating of 10 percent, but not more, for bilateral minimal degenerative changes of the knees is granted; subject to the applicable criteria pertaining to the payment of veterans' benefits. An increased evaluation in excess of 20 percent disabling for residuals of a post-operative fracture of the proximal right humerus with bicep weakness and atrophy of disuse is denied. THERESA M. CATINO Acting Member, Board of Veterans' Appeals