Citation Nr: 0002239 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 98-02 561 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a skin disorder. 2. Entitlement to service connection for a gastrointestinal disorder. 3. Entitlement to an increased rating for a service- connected left knee disability, currently evaluated 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. L. Wasser, Associate Counsel INTRODUCTION The veteran served on active duty from August 1981 to June 1992. This case comes to the Board of Veterans' Appeals (Board) from a September 1997 RO decision which, in pertinent part, denied service connection for a skin disorder and a gastrointestinal disorder, and denied an increase in a 10 percent rating for a service-connected left knee disability. FINDINGS OF FACT 1. The claims for service connection for a skin disorder and a gastrointestinal disorder, including as due to undiagnosed illness from service in Southwest Asia during the Persian Gulf War, are implausible. 2. The veteran's left knee disability (postoperative residuals of a patellar tendon rupture) is manifested by 135 degrees flexion and 0 degrees extension, and no instability. CONCLUSIONS OF LAW 1. The claims for service connection for a skin disorder and a gastrointestinal disorder, including as due to undiagnosed illness from service in Southwest Asia during the Persian Gulf War, are not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The criteria for a rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Codes 5257, 5260, 5261 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran served on active duty in the Army from August 1981 to June 1992, including service in Southwest Asia from December 1990 to April 1991 during the Persian Gulf War. A review of the veteran's service medical records shows that on medical examination performed for enlistment purposes in May 1981, his skin was clinically normal, and his abdomen and viscera were normal with the exception of a history of a right inguinal hernia. A March 1982 treatment note shows that the veteran complained of a one-hour history of stomach pain; the diagnosis was viral gastroenteritis. A February 1985 treatment note shows that the veteran reported a two-day history of right abdominal pain; the initial assessment was possible "gastroitis," and the final diagnosis was constipation. An October 1986 treatment note indicates that the veteran reported a one-day history of nausea and vomiting, with no diarrhea; the diagnosis was enteritis. A September 1987 screening note shows that the veteran complained of a stomach ache which was not severe, with no abnormal vomitus or stools, which had lasted for one day. The veteran was given a self-care protocol. An August 1988 treatment note shows that the veteran was treated for complaints of an itchy rash between the toes of the right foot; the diagnosis was tinea pedis. A May 1989 treatment note shows that the veteran presented with complaints of fever, headaches, chills, weakness, diarrhea, and episodic abdominal pain for the past day. The diagnosis was viral syndrome. A June 1990 treatment note shows that the veteran presented with complaints of diarrhea, vomiting, and abdominal pain for the past four days; he reported that the abdominal pain lasted for one day and then resolved, and that the vomiting and diarrhea began the previous day. On examination, the abdomen was soft with mild generalized tenderness and active bowel sounds. The diagnosis was gastroenteritis. On follow-up examination the next day, the veteran reported that he felt somewhat better; the diagnosis was improving gastroenteritis. A July 1991 treatment note shows that the veteran complained of "fever blisters" on his upper lip; the diagnostic impression was herpes simplex. In an August 1991 memorandum, a physician indicated that the veteran's health records had been reviewed, and a physical examination was not required. Service medical records reflect treatment for left knee pain and are negative for diagnoses of a chronic skin disorder or a chronic gastrointestinal disorder. Private medical records from Cleveland Clinic Foundation dated from March 1992 to July 1992 reflect that the veteran presented with complaints of an acute onset of left knee pain while playing basketball, was diagnosed with a left patellar tendon rupture, and underwent a left patellar tendon reconstruction. Post-operative treatment records reflect that the veteran underwent physical therapy. In a December 1993 decision, the RO established service connection for post-operative residuals of a left patellar tendon rupture, with a 10 percent rating. By a statement dated in April 1995, the veteran submitted a claim for an increased rating for a left knee disability, and claims for service connection for a skin disorder and a gastrointestinal disorder due to service during the Persian Gulf War. At a July 1995 VA general medical examination, the veteran complained of an intermittent groin rash and intermittent early satiety. An abdominal examination was normal. A rash was not noted on examination. The pertinent diagnoses were a subjective report of intermittent early satiety, and history of intermittent groin rash. At an April 1997 VA psychiatric examination, the veteran complained of a groin rash and abdominal pain. By statements dated in December 1997, the veteran asserted that he had continuous problems with his left knee. He reported swelling, pain, and loss of balance due to weakness. He stated that he used over-the-counter medication for his condition at work since the medication prescribed by his doctor caused drowsiness. He said a doctor recommended that he use a knee brace, and was considering surgery for the condition. The veteran complained of itching and painful irritation in his groin, and said he used over-the-counter creams which provided very little relief. He said he had digestive problems, and he became full immediately after he started to eat. He said he could only digest small amounts of food at a time. By a statement dated in March 1998, the veteran's representative said that the veteran recalled having a skin disorder of the groin and a gastrointestinal disorder during service, and the condition still existed. He stated that the veteran's left knee disability was more disabling than currently evaluated, and that his job caused additional pain and impairment in the knee condition. At an April 1998 VA examination of the veteran's skin, the veteran complained of a groin rash, which he said began in 1992, and was manifested by itchy bumps which caused skin discoloration. He stated that he and his wife both had this problem intermittently. He stated that he used over-the- counter medications without much success, and that he had recently used Mycelex ointment which helped. His primary complaint was pruritus, and he denied pain and discharge. On examination, there was involvement of the inguinal areas. There was very little rash, but there was mildly thickened and hyperpigmented skin in the groin area. There was some roughening of the skin without any exudate in the right inguinal region. There were no ulcerations. The diagnostic impression was tinea cruris. The examiner recommended anti- fungal cream, and indicated that it was unclear whether the veteran contracted the condition during military service. At an April 1998 VA gastrointestinal examination, the veteran reported a four-year history of a bloated feeling in his stomach after eating. He also stated that the bloated feeling was constant. He denied abdominal pain, nausea, and vomiting. He stated that his bowel movements were normal, and he denied problems with milk or meat products. He denied heartburn and a feeling of food backing up into his chest. He stated that his stools were brown. He denied feeling sleepy, dizzy, or passing out after meals. He described occasional constipation relieved by laxatives, reported occasional diarrhea, and said he had recently gained weight. He said he was not taking medication for the bloated feeling. On examination, the abdomen was flat, soft and non-tender. There were normoactive bowel sounds. The diagnostic impression was dyspepsia. The examiner indicated that an exact diagnosis was uncertain, and recommended an esophagogastroduodenoscopy At an April 1998 VA orthopedic examination, the veteran complained of non-specific pain in the left anterior knee. He reported that he had been given a hinged knee brace which provided some relief. On examination of the left knee, there was a 15-centimeter linear scar approximately 2 centimeters lateral to the midline over the left knee. It was well- healed with no evidence of sensory loss or subcutaneous tissue loss. It was slightly widened and measured approximately 3 millimeters in width. Range of motion of the left knee was from 0 to 135 degrees. The patella tendon was bulky and symmetric to the contralateral unaffected side by palpation. The left quadriceps muscle was equal in strength to the right. The left knee was stable to varus and valgus testing, and was stable to anterior and posterior drawer tests. Lachman's and pivot shift tests were negative, as were McMurray's and pinch tests. The patella glided appropriately in the groove and there was no patellofemoral crepitance and no tenderness in the peripatellar area. The patella tendon was non-tender to palpation. An X-ray study of the left knee revealed no definite abnormality. The pertinent diagnosis was status post patella tendon rupture of the left knee, with no other interarticular abnormalities. The examiner opined that the veteran had an excellent result from a patella tendon reconstruction with no functional limitations found on current examination. II. Analysis A. Service Connection for a Skin Disorder and a Gastrointestinal Disorder Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. The veteran claims service connection for a skin disorder and a gastrointestinal disorder which he asserts, in part, are due to an undiagnosed illness incurred during his service in the Persian Gulf. His claims present the threshold question of whether he has met his initial burden of submitting evidence to show that his claims are well grounded, meaning plausible. If he has not presented evidence that his claims are well grounded, there is no duty on the part of the VA to assist him with his claims, and the claims must be denied. 38 U.S.C.A. § 5107(a); Grivois v. Brown, 6 Vet. App. 136 (1994). For the veteran's claim for service connection to be plausible or well grounded, it must be supported by competent evidence, not just allegations. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). In order for a service connection claim to be well grounded, it must be supported by competent evidence of a current disability (medical evidence of a diagnosis), competent evidence of incurrence or aggravation of a disease or injury in service (medical evidence or, in some circumstances, lay evidence), and competent evidence showing causality between service and a current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995); Grivois, supra; Grottveit v. Brown, 5 Vet. App. 91 (1993). The veteran served in the Southwest Asia theater of operations from December 1990 to April 1991, during the Persian Gulf War. Service connection may be granted for a disability for a veteran who served in the Southwest Asia theater of operations during the Persian Gulf War when there are objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as fatigue, signs or symptoms involving skin, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, sleep disturbances, etc. Among the requirements for granting service connection for this type of disability are the following: the illness must become manifest during either active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more (under the appropriate diagnostic code of the rating schedule) not later than December 31, 2001; by history, physical examination, and laboratory tests, the disability cannot be attributed to any known clinical diagnosis; there must be objective evidence that is perceptible to an examining physician and other non- medical indicators that are capable of independent verification; a minimum of a 6 month period of chronicity; no affirmative evidence which relates the undiagnosed illness to a cause other than being in the Southwest Asia theater of operations during the Persian Gulf War; and the illness is not due to the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. A well-grounded claim for compensation under 38 U.S.C. § 1117(a) and 38 C.F.R. § 3.317 for disability due to undiagnosed illness generally requires the submission of some evidence of: (1) active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) the manifestation of one or more signs or symptoms of undiagnosed illness; (3) objective indications of chronic disability during the relevant period of service or to a degree of disability of 10 percent or more within the specified presumptive period; and (4) a nexus between the chronic disability and the undiagnosed illness. VAOPGCPREC 4-99. With respect to the veteran's claim of service connection for a skin disorder, the legal provisions concerning compensation for disabilities associated with undiagnosed illnesses from the Persian Gulf War are inapplicable, since a current skin disorder has been diagnosed. VAOPGCPREC 8-98. The current diagnosis is tinea cruris. The Board must therefore consider whether the veteran has submitted a well-grounded claim of service connection for his currently diagnosed skin disorder. Initially, the Board notes that the service medical records are negative for a diagnosis of a chronic skin disorder. The service medical records reflect one instance of treatment for tinea pedis and one instance of treatment for herpes simplex of the lips, and are negative for treatment of a groin rash including tinea cruris. At a July 1995 VA examination, the veteran reported an intermittent groin rash; the diagnosis was a history of intermittent groin rash. At an April 1998 VA examination of the veteran's skin, the veteran complained of a groin rash, which he said began in 1992; the diagnosis was tinea cruris. The veteran has asserted that he incurred a skin disorder during his period of active service. As a layman, he is not competent to render an opinion regarding diagnosis or etiology and his statements do not serve to make his claim well grounded. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Similarly, his self-reported lay history, transcribed in some of the post-service medical records, that his tinea cruris began in service, does not constitute competent medical evidence of causality as required for a well-grounded claim. LeShore v. Brown, 8 Vet. App. 406 (1996). The veteran has not submitted competent medical evidence linking the current tinea cruris with service, and without such evidence, the claim for service connection for a skin disorder is implausible and must be denied as not well grounded. 38 U.S.C.A. § 5107(a); Caluza, supra. Turning to the veteran's claim of service connection for an undiagnosed illness manifested by a gastrointestinal disorder, the Board notes that the service medical records are negative for a diagnosis of a chronic gastrointestinal disorder. Service medical records from the veteran's 1981- 1992 period of service reflect a few episodes of treatment for abdominal pain (all prior to the veteran's service in Southwest Asia from December 1990 to April 1991), with varying diagnoses including viral gastroenteritis and constipation, but do not show a diagnosis of a chronic gastrointestinal disorder, and there are no records of treatment of gastrointestinal complaints during or after the veteran's period of service in Southwest Asia. At a July 1995 VA examination, the veteran reported intermittent early satiety; the diagnosis was a subjective report of intermittent early satiety. At an April 1998 VA gastrointestinal examination, the veteran reported a four- year history of a bloated feeling in his stomach after eating, denied abdominal pain, nausea, and vomiting, and said his bowel movements were normal, with occasional constipation and diarrhea. The diagnostic impression was dyspepsia. The examiner indicated that an exact diagnosis was uncertain. Although the veteran has met the first two requirements for a well-grounded claim for service connection for a gastrointestinal disorder due to undiagnosed illness (i.e., active military service in the Southwest Asia theater of operations during the Persian Gulf War and the manifestation of one or more signs or symptoms of undiagnosed illness), the Board concludes that the veteran has not presented a well- grounded claim, as the medical evidence does not demonstrate objective indications of chronic disability during the relevant period of service or to a degree of disability of 10 percent or more within the specified presumptive period, and as there is no nexus between any chronic disability and the undiagnosed illness (described as dyspepsia at the April 1998 VA examination). VAOPGCPREC 4-99. Thus, the claim for service connection for a gastrointestinal disorder is implausible, and the claim must be denied as not well grounded. 38 U.S.C.A. § 5107(a). B. Increased Rating for a Left Knee Disability The veteran's claim for an increase in a 10 percent rating for his service-connected left knee disability (postoperative residuals of a patellar tendon rupture) is well grounded, meaning plausible. The file shows that the RO has properly developed the evidence, and there is no further VA duty to assist the veteran with his claim. 38 U.S.C.A. § 5107(a). When rating the veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the present level of disability is of primary concern in a claim for an increased rating; the more recent evidence is generally the most relevant in such a claim, as it provides the most accurate picture of the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A § 1155; 38 C.F.R. Part 4. The veteran's left knee disability has been rated as 10 percent disabling under 38 C.F.R. 4.71a, Diagnostic Code 5257. Under this code, a 10 percent rating is assigned for slight impairment of the knee, with recurrent subluxation or lateral instability. A 20 percent evaluation requires moderate impairment. 38 C.F.R. 4.71a, Code 5257. Limitation of flexion of either leg to 60 degrees is rated 0 percent. Flexion limited to 45 degrees warrants a 10 percent evaluation, and flexion limited to 30 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a, Code 5260. Limitation of extension of either leg to 5 degrees is rated 0 percent. Extension limited to 10 degrees warrants a 10 percent evaluation. Extension limited to 15 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a, Code 5261. The medical evidence shows that the veteran has full extension and minimal limitation of flexion of the left knee. On VA examination in April 1998, range of motion was from 0 to 135 degrees. The Board notes that full range of motion is from 0 to 140 degrees. See 38 C.F.R. § 4.71, Plate II. The patella tendon was bulky and symmetric to the contralateral unaffected side by palpation. The left knee was stable to varus and valgus testing, and was stable to anterior and posterior drawer tests. Lachman's and pivot shift tests were negative, as were McMurray's and pinch tests. The patella glided appropriately in the groove and there was no patellofemoral crepitance and no tenderness in the peripatellar area. The patella tendon was non-tender to palpation. An X-ray study of the left knee revealed no definite abnormality. The pertinent diagnosis was status post patella tendon rupture of the left knee, with no other interarticular abnormalities. The examiner opined that the veteran had an excellent result from a patella tendon reconstruction with no functional limitations found on current examination. The range of motion of the veteran's left knee at the April 1998 VA examination is noncompensable under limitation-of- motion Codes 5260 and 5261. There is no evidence that any pain on use of the joint would result in limitation of motion to a compensable degree. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet.App. 202 (1995). The examination showed the left knee was stable; the evidence does not demonstrate the knee now has even slight recurrent subluxation or lateral instability, as required for the current 10 percent rating under Code 5257. See 38 C.F.R. § 4.31. Clearly, moderate recurrent subluxation or lateral instability, as required for a higher rating of 20 percent under Code 5257, is not demonstrated. The Board finds that the preponderance of the evidence is against the claim for a higher rating for the service- connected left knee disability. Consequently, the benefit- of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a skin disorder is denied. Service connection for a gastrointestinal disorder is denied. An increased rating for a left knee disability is denied. L. W. TOBIN Member, Board of Veterans' Appeals