Citation Nr: 0002592 Decision Date: 02/02/00 Archive Date: 02/10/00 DOCKET NO. 98-02 388 ) 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 degenerative changes of the lumbar spine as secondary to a service- connected left knee disability. 2. Entitlement to service connection for entrapment ulnar neuropathy at the left elbow as secondary to a service- connected left knee disability. 3. Entitlement to an increase in a combined 30 percent rating for postoperative residuals of a left knee injury with traumatic arthritis. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Debbie A. Riffe, Associate Counsel INTRODUCTION The veteran served on active duty from June 1973 to March 1976. This case comes to the Board of Veterans' Appeals (Board) in part from a November 1997 RO decision which reduced the rating for the veteran's service-connected postoperative residuals of a left knee injury from 30 percent to 20 percent, effective from February 1998. The veteran testified at an RO hearing in July 1998. In a September 1998 RO decision, a separate 10 percent rating for traumatic arthritis as a postoperative residual of a left knee injury was assigned, effective from February 1998. The veteran's service-connected left knee disability is currently evaluated 20 percent under rating criteria for instability of the knee and 10 percent under rating criteria for arthritis of the knee; the combined rating for the left knee disability is 30 percent. This case also comes to the Board from an August 1998 RO decision which denied service connection for degenerative changes of the lumbar spine and for entrapment ulnar neuropathy at the left elbow, both claimed as secondary to the service-connected left knee disability. The present Board decision addresses the claims for secondary service connection for low back and left elbow conditions. The claim for a higher rating for the left knee disability is the subject of the remand which follows the Board decision. FINDING OF FACT The veteran has not submitted competent evidence to show plausible claims for service connection for degenerative changes of the lumbar spine and for entrapment ulnar neuropathy at the left elbow, claimed as secondary to his service-connected left knee disorder. CONCLUSION OF LAW The veteran's claims for service connection for degenerative changes of the lumbar spine and for entrapment ulnar neuropathy at the left elbow, as secondary to a service- connected left knee disorder, are not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION I. Factual Background The veteran served on active duty from April 1975 to March 1976. Service medical records show he sustained a tear of the left tibial collateral ligament for which he underwent surgical repair in April 1975, and thereafter was treated for complaints of left knee pain. Medical records during service and for many years later reveal no complaints, clinical findings, or diagnosis of either a lumbar spine disability or neuropathy in the left upper extremity. In a September 1979 decision, the RO granted service connection for postoperative residuals of a left knee injury. Medical records show the veteran was treated in the years after service for his service-connected left knee disability, and he had additional left knee operations in 1979, 1986, 1990, and 1993. The records from the late 1980s and early 1990s show left knee instability and use of a brace. An October 4, 1994 report from Pee Dee Orthopaedic Associates indicates the veteran injured his left arm in an industrial accident that day and was to be admitted to McLeod Regional Medical Center for treatment. He complained of pain about the arm and some diffuse paresthesias in his hand without any loss of sensation. An examination of the left arm revealed diffuse swelling from the shoulder to the elbow and an open wound over the mid-lateral arm. The veteran was normal neurovascularly, and his radial nerve appeared to be intact. There was normal sensation to pin prick. X-rays of the upper extremity revealed a three part fracture of the proximal humerus with minimal displacement of the greater tuberosity fracture and a very comminuted displaced fracture of the mid- shaft of the left humerus. The impression was open fracture of the left humerus and a three part proximal humerus fracture on the left. Additional records show the veteran was admitted to the hospital and underwent open reduction and internal fixation of the left humerus fracture. He had additional injuries, apparently from the industrial accident, including a fractured finger of the right hand and multiple contusions and abrasions. There was reference to a soft tissue injury of the mid back and left flank areas. A brachial plexus injury was also noted. The records indicate the veteran's injuries were the subject of a worker's compensation claim. [The Board notes that typewritten copies of the above October 4, 1994 medical record were submitted by the veteran and his representative in May 1997 and August 1998. These copies are virtually identical except for the section concerning patient history. The history portion of the October 4, 1994 medical record, submitted in May 1997, relates, in pertinent part, that the veteran "was working this morning at Superior Machine when he got his cuff caught in some type of machine that twisted him and brought his arm under and into a machine." When the veteran submitted this report in May 1997, he also submitted his own statement (on VA Form 21- 4138) in which he said, "I feel my service connect should by rise while working on my Job at at night, I was standing by my machine and my knee give away and my cuff got caught in my machine if my knee had not give away it would not have happen to." The history portion of the October 4, 1994 medical record, submitted by the veteran's representative in August 1998, relates, in pertinent part, that the veteran "was working this morning at Superior Machine when his left knee gave away and cause him to lose his balance and fell into machine. His cuff got caught in some type of machine."] Records from October 1994 to February 1995 from Pee Dee Orthopaedic Associates indicate ongoing treatment for the veteran's left upper extremity injury. There is no reference in the records to the veteran's left knee disability. A February 1995 report from Roland Skinner, M.D., reflects that the veteran underwent an examination of the upper extremities which showed decreased motor strength and sensation on the left side as compared with the right side. Dr. Skinner indicated in the impression that the veteran probably had a brachial plexus injury involving primarily the upper trunk muscles with some mild weakness of the lower arm (assuming that the veteran was giving full effort) and also some sensory deficit in a C8-T1 distribution. He recommended continuation of physical therapy and an electromyogram (EMG) and nerve conduction study on the left arm. (Only page 2 of Dr. Skinner's report was received, and it was noted on the report that seven other pages of medical records that were received with the report were destroyed as they were duplicative of other evidence previously received.) Records from March to June 1995 from Pee Dee Orthopaedic Associates indicate ongoing treatment for the veteran's left upper extremity injury. In May 1995, the veteran reported discomfort with abduction of his left shoulder and the examiner believed there was an element of impingement. X- rays showed the veteran's fractures were solidly healed. In June 1995, the examiner felt the veteran had reached maximum improvement, despite occasional impingement primarily with abduction which was mild. The examiner believed the veteran was impinging where he had the fracture of the tuberosity and would not recommend surgery for it. The examiner stated that in the future the veteran's intermedullary rod might possibly have to be removed, and opined that the veteran had permanent limitations in his arm with overhead use, lifting, pulling, and pushing of the arm. The examiner deferred to another doctor for a rating or statement regarding a brachial plexus injury. From an orthopedic standpoint, the examiner stated the veteran had a permanent physical impairment in his upper extremity of 35 percent. Medical records also note periodic treatment for the veteran's service-connected left knee disability, including additional surgery in January 1996. A February 1996 record from Dr. Dawson indicates that the veteran reported pain in the right sciatic notch area. He denied having pain in his back at that time. On an examination, straight leg raising was negative on the left and strongly positive on the right, both while sitting. X- rays of the lumbar spine revealed decreased disk space at L5- S1. The diagnosis was sciatica of the right leg. At this visit, the veteran also had left knee complaints. A March 1997 report from Florence Orthopaedic Associates indicates a complaint regarding pain in the left leg; the pain reportedly radiated to the left knee and calf. An examination revealed that straight leg raising on the left caused pain down the lateral aspect of the left leg. X-rays of the lumbar spine showed decreased disk space at L5-S1 and normal alignment, and X-rays of the left knee showed decreased joint space. The diagnoses were left leg pain and sciatica on the left. A December 1997 VA outpatient record indicates that the veteran reported having fractured his left shoulder on the job in 1994 and having a pin from the elbow to shoulder. He reported a history of arthritis in his shoulder and knee joint. The assessment was left knee pain and left shoulder pain. A March 1998 medical record indicates a complaint of low back pain in addition to complaints referable to the left knee. An April 1998 medical record from N. Lee Morris, M.D., indicates that on a physical examination the veteran had lumbar muscle spasms. The impression was lumbar sprain. VA X-rays of the lumbar spine in June 1998 revealed normal alignment, minimal degenerative change at multiple levels, and no acute bony abnormalities. A VA nerve conduction velocity report in June 1998 revealed entrapment ulnar neuropathy at the left elbow and a normal left median nerve. In July 1998, the veteran's representative filed claims for service connection for degenerative changes of the lumbar spine and entrapment ulnar neuropathy at the left elbow, as secondary to the veteran's service-connected left knee disability. It was stated that his left elbow was injured in an industrial accident when his service-connected left knee gave way unexpectedly, causing the left arm to be caught in a piece of machinery. A July 1998 medical record from N. Lee Morris, M.D., indicates that the veteran was complaining of discomfort concerning his knee and back. The impression was degenerative osteoarthritis of the left knee and back. In August 1998, the RO denied the veteran's claim for secondary service connection for degenerative changes of the lumbar spine and for entrapment ulnar neuropathy at the left elbow, as secondary to a service-connected left knee disability, indicating that there was no medical evidence of a relationship between the claimed conditions and the service-connected left knee disability. In his September 1998 substantive appeal, the veteran indicated that he was unable to play sports and that it was difficult to work every day because he could not stand for any length of time. He stated that he lived with pain every day. He asserted that his left knee gave way causing him to be caught in a machine from which he lost 35 percent of the use of his left arm. He stated that he had a pin from his elbow to his shoulder. Medical records in September and October 1998 from N. Lee Morris, M.D., indicate complaints of pain in the back, left shoulder, and left knee. It was noted that the veteran was now wearing a brace. There were no clinical findings pertaining to the back. The impression was osteoarthritis of the left knee in September 1998 and osteoarthritis in October 1998. VA outpatient records in December 1998 indicate complaints of left knee pain, left hand numbness, and back pain. The veteran reported that since he was last seen there three months previously he received a left knee brace and had begun taking non-steroidal anti-inflammatory drugs with some improvement in symptoms. An examination revealed the veteran to be neurovascularly intact. His paravertebral muscles of the spine were tender to palpation, and he had tenderness to straight leg raise that was localized to the back. He had some paresthesias over the left ulnar aspect of the hand radiating up the ulnar aspect of the arm. The assessment was possible cubital tunnel syndrome. The veteran was seen in the kinesiotherapy clinic for a home exercise program for his low back weakness and pain. A December 1998 medical record from N. Lee Morris, M.D., indicates a complaint of pain in the back and knee joint and numbness in the hand and arms. It was noted that the veteran was wearing a left knee brace. The impression was osteoarthritis of the left knee and hypertension. There were no findings or diagnosis pertaining to the lumbar spine or left upper extremity. II. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Secondary service connection may be granted for a disability which is proximately due to or the result of an established service-connected condition. 38 C.F.R. § 3.310. Secondary service connection may be found when an established service- connected condition aggravates a non-service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). A claimant for VA benefits shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. The VA has the duty to assist a claimant in developing facts pertinent to the claim if the claim is determined to be well grounded. 38 U.S.C.A. § 5107(a). Thus, the threshold question to be answered is whether the veteran has presented a well-grounded claim; that is, a claim which is plausible. If he has not presented a well-grounded claim, his appeal must fail, and there is no VA duty to assist him in development of his claim. Id.; Murphy v. Derwinski, 1 Vet. App. 78 (1990). As explained below, the Board finds that the veteran's secondary service connection claims are not well grounded. To sustain a well-grounded claim, the claimant must provide evidence demonstrating that the claim is plausible; mere allegations are insufficient. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Where the determinative issue involves either medical etiology or a medical diagnosis, competent medical evidence is required to fulfill the well-grounded claim requirement of 38 U.S.C.A. § 5107(a ). Grottveit v. Brown, 5 Vet. App. 91 (1993). In order for a claim for service connection to be well grounded, there must be competent evidence of a current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (medical evidence or, in some circumstances, lay evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). The nexus requirement may be satisfied by a presumption that certain diseases manifesting themselves within certain prescribed periods are related to service. Caluza v. Brown, 7 Vet. App. 498 (1995). In the case of a claim for secondary service connection, there must be medical evidence of a nexus between an established service-connected condition and the claimed disability. Libertine v. Brown, 9 Vet. App. 521 (1996). In this case, the veteran contends that he has degenerative changes of the lumbar spine and entrapment ulnar neuropathy at the left elbow which are attributable to his service- connected left knee disability. The medical evidence shows that the veteran had several fractures in his left upper extremity (humerus) as the result of an accident at work on October 4, 1994. The copy of the October 4, 1994 medical record which the veteran submitted in May 1997 notes the patient history of the industrial accident and makes no mention of the left knee being involved. In contrast, the copy of the October 4, 1994 medical record submitted by the veteran's representative in August 1998 contains a recitation of patient history of the left knee giving way before the accident. Given the grammar of this portion of the copy of the report submitted in August 1998, as well as other circumstances, there are serious questions as to whether this copy is authentic. Even assuming that the copy of the report submitted in August 1998 is genuine, the mere recitation of patient history does not consitute competent medical evidence of causality for a well-grounded claim for service connection. LeShore v. Brown, 8 Vet.App. 406 (1995). On follow-up visits in May and June 1995, a private doctor believed that the veteran had impinging where he had the fracture of the tuberosity. X-rays of the lumbar spine in February 1996 and March 1997 show decreased disk space at L5- S1. There was a complaint of low back pain in March 1998, and Dr. Morris diagnosed the veteran with lumbar sprain in April 1998. In June 1998, the veteran was diagnosed by VA with lumbar spine degenerative changes and entrapment ulnar neuropathy at the left elbow, as shown by X-rays and a nerve conduction velocity study. Thereafter, the veteran was seen privately and at the VA for complaints of low back pain, left shoulder pain, and left hand numbness. In reviewing the entire record, the Board finds that what is lacking in establishing a well-grounded claim for secondary service connection in this case is competent medical evidence linking the veteran's degenerative changes of the lumbar spine and entrapment ulnar neuropathy at the left elbow with his service-connected left knee disability. Statements by the veteran, to the effect that his low back disability and left upper extremity neuropathy are attributable to his service-connected left knee disability, do not constitute competent medical evidence, since, as a layman, he has no competence to give a medical opinion on diagnosis or etiology of a disorder. Grottveit v. Brown, 5 Vet. App. 91 (1993). Consequently, the veteran has not met the initial burden under 38 U.S.C.A. § 5107(a) of submitting evidence to show well-grounded claims for secondary service connection for these conditions, and thus the claims must be denied. ORDER Service connection for degenerative changes of the lumbar spine as secondary to a service-connected left knee disability is denied. Service connection for entrapment ulnar neuropathy at the left elbow as secondary to a service-connected left knee disability is denied. REMAND The veteran's claim for an increase in a combined 30 percent rating for postoperative residuals of a left knee injury with traumatic arthritis is well grounded, meaning plausible, and the file indicates there is a further VA duty to assist him in developing facts pertinent to the claim. 38 U.S.C.A. § 5107(a); 38 C.F.R. §§ 3.103, 3.159; Murphy v. Derwinski, 1 Vet. App. 78 (1990). Review of the claims folder shows that the veteran's most recent VA examination was conducted in June 1997. At that time, there was no instability to varus or valgus stress at 30 degrees of flexion, and the veteran's anterior drawer, posterior drawer, and Lachman's were negative. He also complained of pain with ambulation. Since then, he has received private and VA outpatient treatment for knee complaints, to include pain and instability, and he received a brace in 1998 to stabilize his left knee. Given the length of time since the last VA compensation examination, and evidence suggesting the condition has worsened, the Board believes that a current examination is in order. Caffrey v. Brown, 6 Vet. App. 377 (1994). Any recent treatment records should also be obtained. Murincsak v. Derwinski, 2 Vet. App. 363 (1992). Therefore, this issue is REMANDED to the RO for the following development: 1. The RO should contact the veteran and obtain the names and addresses of all health care providers (VA or non-VA) where he has received treatment for left knee problems since his June 1997 VA examination. After receiving this information and any necessary releases, the RO should contact the named medical providers and obtain copies of all related medical records which are not already on file. 2. Thereafter, the veteran should be afforded a VA orthopedic examination to determine the current nature and severity of his service-connected left knee disability. The claims folder should be made available to and reviewed by the examiner in conjunction with the examination. All indicated tests should be performed, to include range of left knee motion in degrees, measured with a goniometer, and an accurate assessment of left knee instability. The examiner should note for the record any objective evidence of pain referable to the left knee, and should assess the degree of additional limited motion or other functional impairment during use or flare-ups due to knee pain, in accordance with DeLuca v. Brown, 8 Vet. App. 202 (1995). All clinical findings must be reported in detail in the examination report. 3. Following completion of the foregoing, the RO should readjudicate the veteran's claim for a higher rating for his left knee disability. If the decision is adverse to the veteran, the RO should provide him and his representative with a supplemental statement of the case and the opportunity to respond. Thereafter, the case should be returned to the Board for further appellate review. While the case is in remand status, the veteran may furnish additional evidence and argument on the issue which the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). L. W. TOBIN Member, Board of Veterans' Appeals