Citation Nr: 0002475 Decision Date: 02/01/00 Archive Date: 02/10/00 DOCKET NO. 98-17 915A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim for service connection for a low back disorder and, if so, whether all the evidence both old and new warrants the grant of service connection. 2. Entitlement to service connection for a low back disorder, claimed as secondary to service-connected left knee disability. 3. Entitlement to an increased rating for postoperative residuals of surgery for chondromalacia of the left knee, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The veteran had active service from October 1977 to October 1981 and from May 1987 to May 1992. This matter comes before the Board of Veterans' Appeals (Board) from a September 1997 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. On June 21, 1999 a video conference hearing was held before the undersigned member of the Board. On the occasion of that hearing, the veteran indicated that he had lost one job due to his service-connected left knee disorder and further noted that his current job had been furnished on account of or with special consideration to his service-connected left knee disorder (page 4). See 38 C.F.R. § 4.18 (1999). In this regard, the veteran appears to be raising a claim for a total rating based on individual unemployability due to service- connected disabilities. This issue is referred to the RO for appropriate action. FINDINGS OF FACTS 1. The veteran had active service from October 1977 to October 1981 and from May 1987 to May 1992. 2. By letter dated March 29, 1993, sent to the veteran's most recent address of record, the RO notified the veteran of a February 1993 rating action denying a claim for service connection for a low back disorder, claimed as incurred during service, and of the denial of service connection for arthritis of the left knee but also of the grant of service connection for chondromalacia of the left patella. No appeal was taken from that rating action. 3. Other than the veteran's testimony, there is no evidence corroborating the non-receipt of the March 29, 1993 notification letter and the presumption of administrative regularity is unrebutted. 4. Additional evidence submitted since the unappealed rating action of February 1993 to reopen the claim for entitlement to service connection for a low back disorder, taken together with evidence previously on file, is new and material and reopens the claim for service connection for a low back disorder but does not establish that the claim is well grounded. 5. The veteran has not submitted evidence sufficient to establish that a current low back disability is causally or etiologically related to his service-connected left knee disorder, as required to justify a belief by a fair and impartial individual that his claim for service connection for a low back disorder, on a secondary basis, is plausible. 6. The veteran is not service-connected for arthritis of the left knee (service connection for arthritis of the left knee having been denied by the unappealed February 1993 rating action) and the left knee disorder is manifested by almost full range of motion, no ligamentous instability, no clinical evidence of menisceal pathology and not more than slight left knee impairment, despite the subjective complaints which are out of proportion with the physical findings. CONCLUSIONS OF LAW 1. The unappealed rating action of February 1993, which denied service connection for a low back disorder, and of which the veteran was notified, is final. 38 U.S.C.A. § 7105(c) (West 1991); 38 C.F.R. §§ 3.104(a), 20.302(a) (1999). 2. Evidence sufficient to rebut the presumption of administrative regularity has not been submitted. Saylock v. Derwinski, 3 Vet. App. 394, 395 (1992); YT v. Brown, 9 Vet. App. 195, 199 (1996); Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994); Ashley v. Derwinski, 2 Vet. App. 62, 65 (1992). 3. The new and material evidence, when considered with the old evidence, is sufficient to reopen the claim for service connection for a low back disorder but does not establish that the claim is well grounded. 38 U.S.C.A. §§ 5107(a), 5108 (West 1991); 38 C.F.R. § 3.156(a) (1999); and Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). 4. The claim of service connection for a low back disorder, claimed as secondary a service-connected left knee disorder, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991) (1999). 5. An evaluation in excess of 10 percent for postoperative residuals of surgery for chondromalacia of the left knee is not warranted on either a schedular or extraschedular basis. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.2, 4.7, 4.10, 4.14, 4.21, 4.40, 4.41, 4.45, 4.59, Diagnostic Code 5257 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Background Service medical records reflect that on January 24, 1979 the veteran complained of low back and suprapubic pain. The assessments were prostatitis versus cystitis. In April 1979, he complained of low back pain, more to the right side, due to physical training for one week. On examination there was spasm in the low back area. The assessment was a questionable low back strain. He was given an ice rub and medication for pain. In September 1980, he complained of shortness of breath, a productive cough, chest pain, and low back pain. The assessment was an upper respiratory infection. Service medical records pertaining to the veteran's left knee reflect that he was seen for left knee pain in 1987 and in July 1988 there was a diagnosis of patellofemoral syndrome. In April 1990, he underwent arthroscopic debridement of a fat pad of the left knee due to fat pad impingement syndrome. In November 1990 it was noted that X-rays revealed left patella narrowing. Also in November 1990 there were assessments of left knee fat pad impingement syndrome as well as retropatellar pain syndrome. He again underwent arthroscopic left knee surgery in December 1990 for debridement of the left anterior fat pad. A March 1992 bone scan revealed mild degenerative changes of the left knee. A medical history questionnaire in conjunction with examination in March 1992 reflects that the veteran complained of having or having had recurrent back pain and a trick or locked knee. With respect to his back pain it was reported that he could not bend over without severe pain. In April 1992, the assessments were left patellofemoral syndrome and mild medial degenerative joint disease (DJD). On VA compensation and pension examination in August 1992 the veteran reported that since 1988 he had complained of low back pain after laying on his back for 6 hours or more. He attributed this to repeated parachute jumps during service. The veteran also noted that he developed low back pain after prolonged walking. He stated that he was undergoing VA physical therapy for his left knee. It was indicated that he was hobbling somewhat, with obvious discomfort in his knees. On physical examination, the veteran walked with a slow gait and an exaggerated limp. He was able to heel and toe walk equally well, and at that time it was noted that his limp disappeared. Lasegue's sign was negative and there were no neurological deficits in the lower extremities. There was no swelling, erythema or crepitus of the left knee but there was slight tenderness over the medial tibial plateau and along the medial aspect of the patella. The knee appeared to be stable, without any laxness of the collateral or cruciate ligaments. McMurray's sign was negative. Left knee extension was to 180 degrees and active flexion was to 19 degrees and passively it was to 151 degrees. He was reluctant to attempt a full deep knee bend because of discomfort in the knee. The impressions included a negative back examination and left chondromalacia patellar with a strong psychological overlay. It was also stated that the diagnosis of arthritis was one and the same problem as his left knee disorder. X-ray study of the lumbosacral spine was negative. Information was received in January 1993 from the National Personnel Records Center indicating that all available service medical records had been sent to the RO in April 1992. A February 1993 rating action granted service connection for chondromalacia of the left patella, status post debridement but denied service connection for arthritis of the left knee and for low back pain. By RO letter dated March 29, 1993 the veteran was notified of that rating action. This RO letter was sent to the address listed by the veteran in VA Forms 21- 4138, Statements in Support of Claim, of January, July, and September 1993. VAOPT records dated in 1993 reflect that in July 1993 the veteran complained of left knee locking. On examination he had no effusion and the collateral and cruciate ligaments were intact but there was medial joint line tenderness. X- rays of the left knee were normal. The assessment was a probable left menisceal injury. Magnetic resonance imaging (MRI) in July 1993 revealed no menisceal tear but revealed effusion and a questionable loose body. In August 1993 it was reported that the MRI had revealed a questionable loose body off of the lateral femoral condyle versus a medial meniscus tear and Grade II signal changes. During VA hospitalization in September 1993 the veteran underwent left knee arthroscopy with resection of plica of the medial compartment and debridement of the cartilaginous flap over the lateral femoral condyle. On admission, the veteran complained of left knee pain and locking since 1991. Prior to surgery, range of motion of the left knee was from 0 to 120 degrees and all ligamentous structures appeared intact but there was a positive McMurray's sign. In September 1993, the RO forwarded to the veteran copies of rating decisions and VA examination reports, as requested by the veteran earlier that month. An October 1993 VAOPT record reveals that the veteran had an injection of steroidal medication into the medial aspect of the left knee and thereafter complained of greatly increased pain and decreased range of motion of the knee. On examination, he had 1+ effusion and diffuse tenderness to palpation, especially over the medial aspect of the knee and decreased range of motion secondary to pain. The assessment was left knee synovitis. A December 1993 VAOPT record reveals that the veteran reported that there had been an improvement with respect to his preoperative pain compared to his post-operative left knee pain, although the pain was different. He denied locking and catching of the knee but there was intermittent swelling. On examination, he had full range of motion of the left knee. There was no effusion but there was marked medial joint line tenderness. There was no medial or lateral ligamentous laxity and Lachman's and Drawer's signs were negative. X-rays were negative for degenerative joint disease (DJD) or a loose body. The assessment was DJD. VAOPT records dated in 1996 and 1997 reflect that in September 1996, the veteran complained of severe pain in the right side of his low back, which was relieved with Motrin. In October 1996, it was reported that he had had a couple of parachute accidents 9 years prior and for the last 5 to 7 years had had constant right sided low back pain which had become worse in the last 6 to 12 months. Also in October 1996, he had low back spasm and the assessments were degenerative lumbar disc and acute lumbar sprain. In November 1996, it was noted that he had been told that he was not eligible for a TENS unit. The assessment was back pain - myofascial vs. unknown etiology. An MRI in November 1996 revealed diffuse bulging at L4-5 and some narrowing of foramina but no evidence of a herniated nucleus pulposus or nerve impingement. The impression was chronic lumbosacral strain. In December 1996, it was reported that he had had low back pain for many years but the pain was much worse in the past year. The low back pain did not radiate to his legs. He had had several parachute accidents during service but no previous work-up for his back. The assessment was low back pain without radiculopathy. In March 1997 a VAOPT record noted that the veteran took Naprosyn with some relief of low back pain. On VA joint examination in September 1997 it was reported that the veteran had had some improvement in his left knee disorder from the 1990 arthroscopic debridement. However, he stated that there had been an increase in left knee grinding which had progressed and caused severe pain. He had had only minimal relief after his 1993 surgery. The veteran reported that he had used a left knee brace since 1990 and the knee felt unstable without the brace. He further noted that he had severe pain at all times, even at rest. The pain was over the anterior aspect of the patella and extended over to the medial aspect of the joint. The veteran reported that he had daily giving out of the left knee. He also had left knee popping and occasional locking as well as occasional minimal swelling. He had recently been treated with a TENS unit for chronic left knee pain. The veteran reported having had low back pain since 1980 which had worsened after a 1990 parachute accident. He now had severe low back pain which radiated to his right thigh and the left side of his waist. He had low back pain on coughing and sneezing. His back disorder had been treated with medication and massages but no actual physical therapy or surgery. On examination the veteran wore a Bledsoe brace on his left knee. He clenched his low back with his right hand and limped severely on his left leg. He appeared very anxious and complained of severe pain in his back and left knee. The examination was limited and difficult to perform due to his level of pain and inability to perform requested tasks. He was unable to flex or extend his lumbar spine without grasping a table for support and complaining of severe low back pain. He wore a TENS unit over his low back. His pain was localized to the right vertebral angle, diffusely, down to the ilium. There was no point of maximal tenderness and it was difficult to ascertain whether the pain was located over the vertebral bodies or in the soft tissue. He also had pain in the right sacroiliac notch. He was unable to raise himself up on his toes or his heels "secondary to compliance." Patellar and achilles reflexes were 2+ and dorsiflexion and plantar flexion of the ankles was 5/5 bilaterally. Extension of the veteran's left knee could not be determined because he had apparent 2+ to 3- active knee extension. This was difficult to understand, based on his injuries. He had severe tenderness to even light palpation over the anterior and medial aspects of the knee. There was no effusion. Instability was difficult to ascertain because he complained of severe pain to touch about the knee. It was reported that he was able to "achieve full extension passively and actively after several minutes, he is able to extend the knee." Flexion appeared to be to at least 90 degrees, but this was difficult to attain. X-rays of the lumbosacral spine were normal except for some anterior spurring over the anterior-superior vertebral body of L5. X-rays of the left knee were normal. The diagnoses were chronic low back pain without evidence of neurocompressive pathology, and chronic left knee pain of underdetermined cause. The examiner noted that it was very difficult to examine the veteran due to his complaints of chronic and severe pain in his low back and left knee. No left knee instability could be detected, although it was difficult to examine him due to pain intolerance. A November 1996 MRI revealed a markedly desiccated L4-5 disc of normal height which had a broad-based convex disc bulge encroaching on both neural foramina. There was no disc herniation. The veteran used medication and a TENS unit for low back and left knee pain. It was unlikely that he would benefit from further surgery. Referral to a pain clinic for biofeedback therapy was recommended as was physical therapy for range of motion and strength. VAOPT records of 1997 and 1998 reflect in March 1997 pelvic traction was recommended for treatment of his low back. In April 1997 the veteran complained of right flank pain which radiated to his right testis. The assessment was that right nephroureterolithiasis was to be ruled out. On VA examination in March 1998, it was reported that the veteran worked only part-time due to his left knee and low back disorders. He had injured his left knee and low back in a parachute accident during service. He still had left knee pain, mainly in the joint line, and grinding in the joint. He had episodes of giving way of the left knee but this seemed to be mainly due to severe pain. He used a left knee brace. He took Naprosyn, Valium, and Soma for pain in that knee and in his back. The veteran reported that his back was the most severe of his disorders and he had pain which radiated across his back, mainly on the right side, and sometimes around the right side of his stomach and flank and even into the right buttock. He denied having bowel or bladder dysfunction. He denied any specific radiation of pain into the lower extremities and no numbness or weakness of the extremities was reported. His low back pain was markedly worse with activity. He did not use a lumbar corset that he had been given because he felt that it did not fit him appropriately. On examination it was noted that the veteran was in a severe amount of discomfort and the entire examination findings seemed out of proportion to his symptoms. He had a markedly left-sided antalgic gait with a stiff-legged left leg. There was no effusion of his left knee. He had diffuse tenderness to palpation, particularly along the joint line. There was no instability to ligament testing. He had a negative McMurray's sign but this testing was markedly painful, as was range of motion testing. No crepitation was noted. He had full extension and flexion to 135 degrees with excruciating pain in his back and knee upon flexion to this point. Examination of the veteran's back revealed a moderate degree of spasm of the paraspinous muscles of the left side of his low back and some tenderness at that site. There was no tenderness of the paraspinous muscles of the right side of his low back. Neurologic testing revealed break-away weakness, globally, in the left lower extremity. There was "no clear weakness, assumed to be secondary to severe pain." He had 2+/4 symmetrical patellar and achilles tendon reflexes. Babinski's was downgoing. There was two beat clonus, bilaterally. No thigh or calf atrophy was noted. X- rays of the lumbosacral spine were unremarkable and an X-ray of his left knee was normal, with the joint space being preserved and without evidence of arthritic change. The diagnoses were lumbar strain and left knee post-traumatic chondromalacia. With respect to weakened movement, excessive fatigability or incoordination of joints, the examiner commented that the veteran seemed to have severe pain with attempts of range of motion of the back and left knee but this was out of proportion to his symptoms and objective physical findings. There was a lack of objective evidence to support weakened motion or fatigability. According to the veteran's severe and incapacitating pain, he would be unable to have other than just trace motion of the back and left knee during one of his flare-ups. It was felt that the veteran's low back disorder was not related to the left knee injury and could have been a result of his parachute injury but the veteran did "not give a clear history indicating such." At the time of the June 21, 1999 video conference hearing, the veteran testified that he had never received notice of the February 1993 RO denial of service connection for a low back disorder and that the RO overlooked service medical records in reaching that decision, including evidence of inservice treatment at Ft. Carson, Colorado in 1979 and post- service evidence of treatment at Ft. Bragg at Trooper Medical Clinical during the early 1990s (page 3, 6 and 9). The veteran stated that if he had received notice in 1993 of the denial of service connection for a low back disorder he would have immediately appealed (pages 6 and 9). He noted that he had been treated for his back disability by VA since service discharge (page 3). The veteran noted that he had also been treated by VA for his back disability immediately following service discharge, in Orlando, Florida (page 7). He further noted that he had low back pain which radiated down into his left testicle and also all the way down his legs (page 7). He stated that he had declined to have recommended spinal fusion and took a lot of Naproxen and also took Baclofen, as well as Diazepam to relax and sleep (page 7). He also noted that he had been treated for a back disability several times during service while at Ft. Carson, Colorado and also when he was stationed in Panama, as well as during his second enlistment when he was with the 82nd Airborne Division and when he was with the 307 Medical Battalion (page 8). During his second enlistment he was often given Motrin and other pills (page 8). He stated that he had had several back injuries while at Ft. Carson and also from performing parachute jumps in the 82nd Airborne (page 8). The veteran testified at the June 1999 hearing that he used a brace and a transcutaneous nerve stimulator (TENS) unit for relief of knee discomfort (page 2). It was difficult for him to squat, kneel, walk and simply move the left knee due to pain and discomfort causing great limitation of employment opportunities and he had been unable to hold substantially gainful employment because of his knee and back disorder (pages 3 and 4). He pointed out that he was reluctant to have surgery a third time on his left knee, as had been recommended (page 5). For his left knee, he took Flexeril, Naproxen, Baclofen [sic] and some other strong medications (page 5). He stated that he had constant left knee pain (page 5). He noted that he had received no private post- service medical treatment, having been treated only by VA (page 6). The veteran testified that he had instability and pain in the left knee and medication provided only temporary relief of pain (page 10). He also noted that he wore a left knee brace on a daily basis and worked as an auto body technician but was unable to meet his production quotas (page 11). Low Back Disorder The veteran was notified on March 29, 1993 of a rating decision in February 1993 denying service connection for a low back disorder but no appeal was taken from that rating action. Under 38 U.S.C.A. §§ 5108, 7105(c) (West 1991) and 38 C.F.R. §§ 3.104, 20.302(a) (1998) a rating action which is not appealed is final and may not be reopened unless new and material evidence is presented. New and material evidence is jurisdictional, i.e., if new and material evidence is not submitted to reopen a previously denied claim, the Board is without jurisdiction to adjudicate the merits. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Administrative Regularity The veteran testified that he did not receive notice of the February 1993 denial of service connection for a low back disorder. However, principles of administrative regularity dictate a presumption that government officials have properly discharged their official duties. In the absence of clear evidence to the contrary, it must be presumed that officials at the RO properly discharged their duties by mailing notification to the latest address then of record. See Saylock v. Derwinski, 3 Vet. App. 394, 395 (1992). This is particularly true when, as here, the letter was sent to the most recent address of record in March 1993 and was not returned as undeliverable. An appellant's testimony of nonreceipt does not by itself constitute the type of clear evidence needed to rebut the presumption of regularity that the notice was sent. YT, 9 Vet. App. at 199; see also Mindenhall, 7 Vet. App. at 274; Ashley, 2 Vet. App. at 65. Because the preponderance of the evidence is against the veteran as to this matter, the doctrine of resolution of doubt in favor of a claimant is not applicable. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). Reopening In Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998) (decided September 16, 1998), the United States Court of Appeals for the Federal Circuit (hereinafter "Federal Circuit") held that in Colvin v. Derwinski, 1 Vet. App. 171, 174 (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) impermissibly defined "material evidence" as requiring, for reopening of a previously denied claim, that such evidence establish "a reasonable possibility that the new evidence, when viewed in the context of all the evidence, both new and old, would change the outcome." The new standard established in Hodge is lower than that in Colvin and requires only that the new and material evidence is so significant that it must be considered to fairly decide the merits of the claim. "[A]ny evidence found to be material under the more stringent Colvin test would also have to be found to be material under the more flexible Hodge standard." Fossie v. West, 12 Vet. App. 1, 4 (1998). The Hodge test "calls for judgment as to whether new evidence [] bears directly or substantially on the specific matter." Fossie, at 4. New evidence can be material if it provides a more complete picture of circumstances surrounding the origin of an injury or disability. Elkins v. West, 12 Vet. App. 209, 214 (1999) (en banc). If no new evidence is submitted, no further analysis of materiality is required since evidence which is not new can not be both new and material. Smith (Russell) v. West, 12 Vet. App. 312, 315 (1999). Moreover, if there is no new and material evidence, the Board is without jurisdiction to proceed further, Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996), and there the analysis must end. Butler v. Brown, 9 Vet. App. 167, 171 (1996). There is now a three-step analysis in applications to reopen a final previously denied claim under 38 U.S.C.A. § 5108 (West 1991). First, there must be evidence submitted since the last disallowance on any basis, i.e., on the merits or denying reopening (Evans v. Brown, 9 Vet. App. 273, 285 (1996)), which is new (i.e., noncumulative evidence, not redundant, and not previously submitted) and material (i.e., that which bears directly and substantially on the issue) and, by itself or together with evidence previously on file, is so significant that it must be considered to fairly decide the merits of the claim. In this regard, VA evidence which was constructively on file at the time of the last disallowance on any basis, under Bell v. Derwinski, 2 Vet. App. 611, 613 (1992), may be new if now actually on file, if it otherwise is new and material evidence (i.e., it must still not be cumulative and must be relevant). Smith (Russell) v. West, 12 Vet. App. 312, 314-15 (1999). Second, if new and material evidence is presented, the claim is reopened and it must be immediately determined whether, based on all the evidence, the reopened (not the original) claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991) (since a reopened claim is not necessarily well grounded). This is because the Hodge decision effectively decoupled the previously announced relationship between determinations of well groundedness and of new and material evidence (the difference, if any, between evidence required for well groundedness and that which constitutes new and material evidence appears to be of slight degree; Molloy v. Brown, 9 Vet. App. 513, 516 (1996) (citing Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992) and Edenfield v. Brown, 8 Vet. App. 384, 390 (1995)(en banc)). Elkins v. West, 12 Vet. App. 209, 214 (1999). In both the determinations of reopening and well groundedness, the credibility of the evidence, but not necessarily its competence, is presumed if it is not inherently false, untrue, or patently incredible, but the full weight of such evidence is not assumed. However, neither the doctrine of the resolution of the benefit-of-the- doubt, at 38 U.S.C.A. § 5107(b) nor the duty to assist in obtaining relevant evidence, at 38 U.S.C.A. § 5107(a), is applicable. Third, if the reopened claim is well grounded, it must then be adjudicated de novo, after ensuring that the duty to assist has been fulfilled, and with application of the benefit-of-the-doubt rule. Elkins v. West, 12 Vet. App. 209, 214-218 (1999) and Winters v. West, 12 Vet. App. 203, 206-06 (1999) (en banc) (citing Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998)). The claim for service connection for a low back disorder was denied in 1993 because the RO found that the complained of low back pain during service was acute and transitory and the VA examination in 1992 found no chronic back disorder. There is now evidence that the veteran does have a chronic back disorder. Accordingly, the new evidence is so significant that it must be considered to fairly decide the merits of the claim. Thus, the next step is to determine if the reopened claim is well grounded. In determinations of well groundedness, the evidence required depends upon the issue. Where the issue requires medical expertise, i.e., medical causation or a medical diagnosis, competent medical evidence is required and not lay testimony (since lay persons are not competent to offer medical opinions) but lay evidence will suffice if the disability is of the type to which lay observation is competent to identify. Savage v. Gober, 10 Vet. App. 488, 495 (1997) (no lay competence to provide medical opinion linking present arthritis to an inservice fall); Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993) (lay assertion of medical causation cannot constitute competent evidence for well groundedness); Layno v. Brown, 6 Vet. App. 465, 470 (19994) (lay evidence is competent only when it addresses the features or symptoms of disability but not medical causation); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992)). A well grounded claim for service connection requires medical evidence of (1) a current disability; (2) medical or, in certain circumstances, lay evidence of incurrence or aggravation of a disease or injury in service; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Under 38 C.F.R. § 3.303(b) when a disease shown to be chronic in service (or in a presumptive period) so as to permit a finding of service connection, subsequent manifestations, however remote, are service connected, unless clearly attributable to intercurrent causes. However, not every symptom manifested during service will permit service connection of a chronic illness which is first shown as a clear-cut clinical entity, at some later date. Demonstrating the inservice presence of a chronic disease requires a combination of manifestations sufficient to identify it and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. The third Caluza element (evidence of nexus) may be met by the presumptions pertaining to chronic diseases. With respect to chronic diseases, 38 C.F.R. § 3.303(b) may be applied when there is evidence of (i) the existence of a chronic disease inservice or in a presumptive period (and the evidence need not be contemporaneous with service or a presumptive period but may be evidence, including lay evidence when applicable, years thereafter) and (ii) present manifestations of the same chronic disease. Savage v. West, 10 Vet. App. 488, 495 (1997). When a condition during service is not chronic and there is no medical evidence on file of a causal nexus, continuity of symptomatology is required and may be shown by medical or lay evidence, as appropriate. 38 C.F.R. § 3.303(b) (1998); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); Godfrey v. Brown, 7 Vet. App. 398, 406 (1995); Hickson v. West, 12 Vet. App. 247, 253 (1999) (replacing Hickson v. West, 11 Vet. App. 374 (1999) (decided August 17, 1998)). The second (inservice disability) and third (nexus evidence) elements in Caluza can be satisfied under the continuity provision of 38 C.F.R. § 3.303(b) by (a) evidence that a condition was 'noted' during service or in a presumptive period; (b) evidence showing post-service continuity of symptomatology (evidence of treatment is not required); and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Arms v. West, 12 Vet. App. 188, 193 (1999). Even under this regulation, medical evidence is required to demonstrate a relationship between current disability and the continuity of symptoms, if the condition is not one where lay observation is competent. Clyburn v. West, 12 Vet. App. 296, 301-02 (1999). During this appeal the merits of the issue have been considered by the RO and addressed by the veteran and his representative. Inasmuch as the substantive merits and not merely the procedural aspects of reopening of the claim have been considered and addressed, there can be no question that the Board's determination as to the well groundedness of the claim, without first being addressed by the RO, is in any way prejudicial to the veteran. Generally see Bernard v. Brown, 4 Vet. App. 384 (1993) (as to Board adjudication of a question not adjudicated by the RO). While the veteran now meets the first and second Caluza criteria of competent medical evidence of current disability and evidence of inservice symptoms, with the inservice symptoms not being shown to establish the presence, at that time, of chronic disability, there is no competent medical evidence of a nexus between the two (the third Caluza criteria). This was specifically commented upon by the 1998 VA examiner who stated that the veteran did not give a clear history indicating such a relationship, although such a relationship was a possibility. However, the mere existence of a possible relationship is insufficient to establish a well grounded claim when taken in the context of the 1998 VA examiner's observation that a history sufficient for such a conclusion had not been related. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Board may not use it's own independent medical judgment but, rather, is confined to the medical evidence of record. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Here, there is no competent medical evidence rebutting the medical opinion expressed by the 1998 VA examiner. Contrary to contentions, service medical records do not document inservice back injuries in parachutes jumps or treatment for a low back disorder in the 1990s. Also, there are no corroborating VA treatment records in the immediate post-service years. Rather, VAOPTs from Orlando, Florida in 1992 and 1993 reflect treatment for left knee disability and no complaints pertaining to his low back. Thus, there is no contemporaneous post-service clinical evidence of continuity of symptomatology and in light of other evidence of inconsistency between the veteran's complaints and objective physical findings, the veteran's testimony is of insufficient probative value as to supplant the absence of objective evidence of continuity of symptomatology. Accordingly, the claim for service connection for a low back disorder is, upon reopening, determined not to be well grounded. Secondary Service Connection At the time of the 1993 rating action there was no allegation that the veteran's current low back disability was due to or the result of his service-connected left knee disorder. Thus, the RO did not, in 1993, adjudicate secondary service connection under 38 C.F.R. § 3.310(a) which provides that secondary service connection is warranted when a disability is proximately due to or the result of a service-connected disease or injury (38 C.F.R. § 3.310(a)). Also, although not alleged to be applicable in this case, service connection is warranted to the extent of any increase, there is aggravation, i.e., additional disability, of a nonservice- connected disability due to a service-connected disorder. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). To establish a well-grounded claim for service connection for a disorder on a secondary basis, the veteran must present medical evidence to render plausible a connection or relationship between the service-connected disorder and the new disorder. Jones v. Brown, 7 Vet. App. 134 (1994). Evidence submitted in support of the claim is presumed to be true for purposes of determining whether the claim is well- grounded. King v. Brown, 5 Vet. App. 19, 21 (1993). However, lay assertions of medical diagnosis or causation do not constitute competent evidence sufficient to render a claim well-grounded. Grottveit v. Brown, 5 Vet. App. 91, 93 (1992); Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). Here, the only competent medical evidence of whether there is a medical, causal or etiological relationship between the service-connected left knee disorder and the claimed low back disorder is the opinion expressed by the 1998 VA examiner who stated that there was no such relationship. Accordingly, the claim for service connection for a low back disorder, on the basis of it being claimed as secondary to the service-connected left knee disorder, is not well grounded. Left Knee Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate Diagnostic Codes (DCs) identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. VA must consider all potentially applicable regulations and explain the reasons and bases for all conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These include, but are not limited to, 38 C.F.R. §§ 4.1 and 4.2 which require that each disability be viewed in relation to its entire recorded history, that there be emphasis upon the limitation of activity imposed by the disabling condition, and that each disability be considered from the point of view of the veteran working or seeking work. Not all disabilities will show all the findings specified in the rating criteria but coordination of the rating with functional impairment is required. 38 C.F.R. § 4.21. The higher of two evaluations will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Consideration may not be given to factors wholly outside the rating criteria provided by regulation. Massey v. Brown, 7 Vet. App. 204, 208 (1994) (citing Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992)). In a claim for an increased rating it is the present level of disability which is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The record reflects that the veteran is service-connected for a knee disability that has been evaluated under the criteria of 38 C.F.R. § 4.71a, DC 5257. In addition, the Board will consider the diagnostic criteria of 38 C.F.R. § 4.71a, DCs 5256, 5258, 5260, and 5261 for evaluating the knee impairment. Where there is recurrent subluxation, lateral instability, or other impairment of a knee, a 10 percent evaluation may be assigned where the disability is slight; a 20 percent evaluation will be assigned for moderate disability; and 30 percent for severe disability. 38 C.F.R. 38 C.F.R. § 4.71a, DC 5257. Under 38 C.F.R. § 4.71a, DC 5258, a 20 percent evaluation, the highest and only rating available under that schedular provision, may be assigned where there is evidence of dislocated cartilage, with frequent episodes of "locking," pain, and effusion into the knee joint. 38 C.F.R. § 4.71a, DC 5256 provides that a 30 percent evaluation is warranted when the knee is ankylosed in a favorable angle in full extension, or in slight flexion between zero degrees and 10 degrees. Symptomatic residuals of removal of a semilunar cartilage warrants a 10 percent ratings. 38 C.F.R. § 4.71a, DC 5259. Ratings under DC 5259 require consideration of 38 C.F.R. §§ 4.40 and 4.45 because removal of a semilunar cartilage may result in complications producing loss of motion. VAOGCPREC 9-98. 38 C.F.R. § 4.71a, DC 5003 provides for rating of arthritis of the knee on the basis of limitation of motion and not instability; whereas, DC 5257 provides for rating of instability of a knee without consideration of limitation of motion. Thus, separate ratings for arthritis of a knee, when there is actual limitation of motion, and for instability of the knee may be assigned without pyramiding, which is prohibited by 38 C.F.R. § 4.14. VAOGCPREC 23-97. Normal range of motion of a knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Evaluations for limitation of flexion of a knee are assigned as follows: flexion limited to 60 degrees is zero percent; flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a, DC 5260. Evaluations for limitation of extension of the knee are assigned as follows: extension limited to five degrees is zero percent; extension limited to ten degrees is ten percent; extension limited to 15 degrees is 20 percent; extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. 38 C.F.R. 38 C.F.R. § 4.71a, DC 5261. In Johnson v. Brown, 9 Vet. App. 7, 11 (1996) it was held that a rating for subluxation of a knee under 38 C.F.R. § 4.71a, DC 5257 was not "predicated on loss of range of motion, and thus [38 C.F.R.] §§ 4.40 and 4.45, with respect to pain, do not apply." However, in VAOGCPREC 9-98 it was held that for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. In other words, a compensable degree of limited motion under DCs 5260 and 5261 need not be shown; rather, a compensable rating may be granted, in addition to a rating for instability under DC 5257, if there is X-ray evidence of arthritis and also painful motion under 38 C.F.R. § 4.59. Here, service connection for arthritis of the left knee was denied by a final unappealed rating action in February 1993. Accordingly, symptoms stemming from arthritis of the left knee, including limitation of motion and pain, which are attributable to such arthritis are not for consideration in determining the appropriate rating for the service-connected left knee disorder. Recent examinations indicate that the veteran's left knee complaints are out of proportion with objective physical findings. For example, he has complained of giving way of the left knee but there is no clinical evidence of ligamentous instability and while there was some speculation that such giving way might be due to weakness, there is no corresponding muscular atrophy of the muscles of the left lower extremity. Most recently he had full extension and almost full flexion of the left knee, while accompanied with his complaint of excruciating pain. While there has been some diagnostic speculation as to whether the veteran had a tear of a cartilage within the left knee, this has never been documented, not even during the most recent surgery in 1993. While the Board does not minimize the disability resulting from the service-connected left knee disorder, the veteran's subjective complaints do not provide a basis, even when considered with the minimal objective clinical findings, for a rating in excess of the current 10 percent rating in effect. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case that claim is denied. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. § 3.102; Gilbert v. Derwinski 1 Vet. App. 49 (1990). In this case, for the foregoing reasons and bases, the preponderance of the evidence is against the claim for an increased rating for the service-connected left knee disorder and, thus, there is no doubt to be resolved in favor of the veteran. ORDER The claim for service connection for a low back disorder, claimed as incurred during service, is reopened but upon reopening is denied on the basis that the claim is not well grounded. (CONTINUED ON NEXT PAGE) The claim for service connection for a low back disorder, claimed as secondary to service-connected left knee disability, is denied as not well grounded. An increased rating for postoperative residuals of surgery for chondromalacia of the left knee is denied. A. BRYANT Member, Board of Veterans' Appeals