Citation Nr: 0003824 Decision Date: 02/14/00 Archive Date: 02/15/00 DOCKET NO. 96-18 390 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for bilateral carpal tunnel syndrome. 2. Entitlement to an increased evaluation for chondromalacia of the left knee, currently rated as 10 percent disabling. 3. Entitlement to an increased evaluation for migraine headaches, currently rated as 10 percent disabling. 4. Entitlement to a compensable evaluation for epigastric ventral hernia. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD S. L. Smith, Counsel INTRODUCTION The veteran had active service from October 1979 to November 1990. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The veteran appeared at a video hearing before the undersigned Member of the Board in November 1999. The Board notes that the veteran at her November 1999 hearing, indicated that she only wished to pursue her appeal as to the issues of entitlement to service connection for bilateral carpal tunnel syndrome, and entitlement to increased evaluations for her service connected chondromalacia, left knee, migraine headaches, and epigastric ventral hernia. In light of 38 C.F.R. § 20.204 (1999) and the holding of the United States Court of Appeals for Veterans Claims (formerly known as the United States Court of Veterans Claims) (Court) in Tomlin v. Brown, 5 Vet. App. 355 (1993), the Board finds the transcript of the hearing to constitute written notice of the withdrawal of appeal of the issues of entitlement to service connection for an eye disorder, residual yeast infection, a foot and leg disorder, as well as the issue of whether new and material evidence had been presented to reopen a claim of service connection for a right knee disorder. FINDINGS OF FACT 1. Service medical records contain no evidence relative to carpal tunnel syndrome (CTS) of either arm. 2. The earliest post-service objective medical evidence of CTS is VA medical records dated in 1994 showing diagnosis and treatment of left CTS. 3. The veteran has a current diagnosis of bilateral CTS, which has not been shown by competent objective evidence to be related to her prior active service. 4. The veteran's service-connected left knee disability is currently manifested by subjective complaints of recurrent pain, swelling, and giving way; and objective findings of range of motion from 140 to 0 degrees, slight retropatellar crepitus with squats, normal X-ray of the left knee joint, and no evidence of instability. 5. The veteran's ventral hernia is not currently objectively shown to be symptomatic or to require the use of a belt for support. 6. The veteran's migraine headaches are not manifested by characteristic prostrating attacks averaging at least once a month over the last several months nor have they necessitated reductions in earning capacity as a result. CONCLUSIONS OF LAW 1. Bilateral carpal tunnel syndrome was not the result of disease or injury which was incurred in or aggravated during active service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). 2. The schedular criteria for an increased rating, in excess of 10 percent, for chondromalacia of the left knee, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 3.321, Part 4, Diagnostic Codes 5003-5261 (1999). 3. The schedular criteria for a compensable rating for ventral hernia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, Part 4, Diagnostic Code 7339 (1999). 4. The schedular criteria for an increased rating, in excess of 10 percent, for migraine headaches, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4 to include §§ 4.7, 4.10, and Diagnostic Code 8100 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service connection for bilateral carpal tunnel syndrome The Board concedes that the veteran has presented a claim which is "well-grounded" or plausible within the meaning of 38 U.S.C.A. § 5107(a). Specifically, the Board notes that there is competent medical evidence of current diagnosis of carpal tunnel syndrome (CTS); lay evidence of incurrence of numbness of the digits in service; and a medical opinion that such numbness is "most consistent" with service-era onset of CTS. The Board is also satisfied that the duty to assist mandated by 38 U.S.C.A. § 5107(a) has been fulfilled as there is no indication of additional available evidence which would be relevant to the veteran's claims. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated in service. 38 U.S.C.A. §§1110, 1131, 1137, 5107 (West 1991 & Supp. 1999); 38 C.F.R. § 3.303 (1999). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (1999). However, continuity of symptoms is required where the condition in service is not, in fact, chronic or where diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b) (1999). In addition, 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 U.S.C.A. § 1113(b) (West 1991 & Supp. 1999); 38 C.F.R. § 3.303(d) (1999). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Review of the veteran's service medical records revealed no evidence as to complaints, treatment, or diagnosis of carpal tunnel syndrome or any other chronic wrist/arm disorder. Treatment records do show that the veteran was seen in April 1986, following sprain of both wrists; however, x-rays were normal. In May 1987, the veteran was noted to complain of a small cyst on the right hand which affected the ring finger. Subsequent service medical records are silent as to any complaint or finding relative to any disability of the arms or wrists. The veteran has testified and has stated in numerous written documents that her problems with bilateral carpal tunnel syndrome began while she was in the service in 1989. At that time she experienced numbness of the hands and was allegedly diagnosed to have carpal tunnel syndrome. The veteran asserts that the problem did disappear with the birth of the child but then reappeared in 1990 after her discharge from service. However, the service medical records do not show any treatment for such an incident. It is noted that the RO requested additional service medical clinical records in August 1997; however, the additional records obtained also contained no reference to carpal tunnel syndrome or any other arm, wrist or hand disorder. There is also no reference to any such problem on the service separation examination report or medical history report, dated September 1990. The Board further notes that the veteran made no reference to any such disability on her initial claim for service connection received in July 1992. In fact, the earliest post-service medical evidence of carpal tunnel syndrome is VA medical records dated in 1994 showing surgical treatment for left carpal tunnel syndrome. At that time, there was no clinical findings or medical opinion as to any link to the veteran's prior service. Report of VA examination conducted in May 1997, noted that the veteran gave a history of vague dysesthesia as early as 1990 in the fingertips. Based on this history, as reported by the veteran, the examining physician opined that this history of digit numbness in 1990 "is most consistent with service-era onset of carpal tunnel syndrome." In response to an additional request for medical opinion, a written "Neurological Opinion", dated March 1998, indicated that the veteran's claims folder had been reviewed. It was noted that carpal tunnel syndrome had been documented on the May 1997 VA examination and the current medical reviewer had "nothing further to add". Based on the evidence of record and the applicable law and regulations, the Board finds that the preponderance of the evidence is against the veteran's claim for service connection for carpal tunnel syndrome. Although the veteran's statement of in-service numbness of the tips of the fingers must be presumed credible for purposes of determining a wellgrounded claim, there is no such presumption when the issue is reviewed on the merits. In light of the complete absence of any reported complaint or finding relative to such disorder in service or at separation as well as the veteran's failure to include it in her earlier claim, the Board finds the veteran's post-diagnosis statements of in-service hand numbness less than credible. Hence the Board finds that, despite the May 1997 statement of the VA examiner, the preponderance of the evidence is clearly against the claim. There is no objective evidence of symptomatology in service or after service until 1994. Furthermore, the veteran does not allege continuity of symptomatology, but rather that the symptoms experienced in service reappeared after service. Although the VA examiner in May 1997 found the history as related by the veteran to be consistent with the in-service onset of the disorder, this statement based solely on the totally unsubstantiated history of the veteran cannot be regarded as competent evidence of in-service incurrence of disease as the medical examiner had no personal knowledge of such facts. Thus, the Board concludes that, in this case, the preponderance of the evidence is clearly against the claim; consequently, entitlement to service connection for bilateral carpal tunnel syndrome must be denied. II. Increased ratings for chondromalacia of the left knee, migraine headaches, and epigastric ventral hernia Initially, the Board finds that the veteran has submitted evidence which is sufficient to justify a belief that her claims for increased ratings are well grounded. 38 U.S.C.A. § 5107(a) (West 1991) and Murphy v Derwinski, 1 Vet. App. 78 (1990). That is, she has presented claims which are plausible. Generally, a claim for an increased evaluation is considered to be well grounded. A claim that a condition has become more severe is well grounded where the condition was previously service-connected and rated, and the claimant subsequently asserts that a higher rating is justified due to an increase in severity since the original rating. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). VA has a duty to assist the appellant to develop facts in support of a well-grounded claim. 38 U.S.C.A. § 5107(a) (West 1991) and Murphy v. Derwinski, 1 Vet. App. 78 (1990). VA examination and radiological evaluations were performed pursuant to the veteran's claims for benefits. Also, all available service medical records and treatment records have been obtained. For these reasons, the Board finds that VA's duty to assist the appellant, 38 U.S.C.A. § 5107(a) (West 1991), has been discharged. Furthermore, the undersigned finds that this case has been adequately developed for appellate purposes. A disposition on the merits is now in order. In evaluating the appellant's request for increased ratings, the Board considers the medical evidence of record. The medical findings are compared to the criteria in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (1999). In so doing, it is the Board's responsibility to weigh the evidence before it. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In evaluating service-connected disabilities, the Board looks to functional impairment. The Board attempts to determine the extent to which a service-connected disability adversely affects the ability of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. §§ 4.2, 4.10 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b) (West 1991). A. Left knee chondromalacia (previously rated as retropatellar pain syndrome) Historically, the veteran was diagnosed and treated for retropatellar pain syndrome of the left knee in service. Following her discharge from service, the RO in an April 1993 rating decision, awarded service connection for retropatellar pain syndrome of the left knee and assigned a 10 percent evaluation under the rating criteria of Diagnostic Code 5257, for impairment of the knee. VA outpatient treatment record of the orthopedic clinic, dated January 1995, indicated that the veteran was seen for bilateral knee pain, worse on the left as well as complaint of mild giving way and mild swelling. Physical examination revealed mild patellar tenderness, and range of motion from 0 to 130 degrees. Mild crepitus was also noted. The assessment was bilateral chondromalacia, more severe on the left. VA radiographic report dated November 1995, interpreted x- rays of the knees as normal. Report of VA examination conducted in September 1996, noted normal appearing knees with range of motion of 0 to 140 degrees, and mild crepitus. The diagnosis was retropatellar pain syndrome with mild retropatellar crepitus. Report of VA examination conducted in May 1997, noted normal appearing knees, range of motion of 0 to 140 degrees, and isolated minimal retropatellar crepitus on weight bearing range of motion. X-rays were negative for abnormality. The final diagnosis was retropatellar pain syndrome with mild retropatellar crepitus on joint range of motion weight-bearing in the knees and squat. VA outpatient orthopedic clinic records dated July 1997, indicated complaints of left knee pain with mild giving way but no locking. The veteran denied any limitation to walking. Physical examination revealed range of motion from 0 to 110 degrees, with negative Lochaman, and no objective evidence of laxity. Crepitation was noted. The assessment was bilateral knee pain secondary to degenerative joint disease, worse on the left. A VA physical therapy record, also dated July 1997, noted range of motion of the left knee to be 10 to 110 degrees. The veteran was noted to present with moderate-severe pain as well as moderate edema of the left knee. By rating decision dated March 1999, the RO reevaluated the veteran's service-connected left knee disability as Chondromalacia (previously retropatellar pian syndrome) and increased the assigned disability evaluation from noncompensable to 10 percent disabling, by analogy to the rating criteria of Diagnostic Code 5010 (for traumatic arthritis). The veteran recently testified at a video hearing conducted in October 1999, before the undersigned Member of the Board that her left knee gives out at times. When she is on her feet all day, the left knee swells and aches. She has a prescribed knee brace and takes Naprosyn. The Board does not find that the evidence supports a rating in excess of the currently assigned 10 percent disability rating under Diagnostic Code 5010 which provides that traumatic arthritis is to be rated as degenerative arthritis. 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 involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Code 5003 (1999). Ratings for limitation of extension of the leg range from 0 to 50 percent based upon the degree to which extension is limited. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (1999). For a compensable, or 10 percent, evaluation, under Diagnostic Code 5261 extension of the knee must be limited to 10 degrees. The Board notes that the veteran's VA treatment records from 1997 do show range of motion from 10 to 110 degrees. Thus, a 10 percent rating would be warranted under Diagnostic Code 5261. However, for a higher disability evaluation, extension would need to be limited to 15 degrees or higher. As the medical evidence shows, the veteran's extension of the knee is not limited to 15 degrees. Therefore, a rating in excess of 10 percent, is not warranted under Diagnostic Code 5261. Ratings for limitation of flexion of the leg range from 0 to 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (1999). Again, those ratings are based on the degree to which flexion is limited. For the lowest, noncompensable, rating under Diagnostic Code 5260, flexion of the knee must be limited to 60. As noted above, the medical evidence reveals that the veteran's range of motion of the knee is significantly greater than that measurement. Therefore, an increased evaluation is not warranted under Diagnostic Code 5260. The Board further finds that the evidence does not support a higher rating under the criteria of Diagnostic Code 5257. The most recent medical evidence, the 1997 VA examination and treatment records, noted that the knee was stable although the treatment records show some limitation of motion. Historical review of the veteran's medical records also show repeated negative findings of instability. When the entire medical evidence is viewed in its entirety, there is no evidence of moderate instability or lateral subluxation. Thus, the Board finds that the current evaluation of 10 percent is appropriate under Diagnostic Code 5257, and a higher evaluation is not warranted under this Diagnostic Code. The Board has also considered the application of other Diagnostic Codes referable to the knee. As there was no evidence of ankylosis of the knee, Diagnostic Code 5256 is not for application. 38 C.F.R. § 4.71a, Diagnostic Code 5256 (1999). Likewise, there is no medical evidence of dislocated or removed semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum, as residuals of the service- connected left knee injury. Thus, Diagnostic Codes 5258, 5259, 5262, and 5263 are not for application. The Board has considered the application of 38 C.F.R. §§ 4.40 (consider "functional loss" "due to pain") and 4.45 (consider "[p]ain on movement, swelling, deformity, or atrophy on disuse" in addition to "[i]nstability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing", incoordination, and excess fatigability) in this case. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). However, an increased rating is not warranted on the basis of these regulations. The evidence of record shows that the veteran's primary complaint is of pain which is caused by prolonged standing or walking. She has indicated that this pain is relieved somewhat by medication and limiting her activities. The post-service medical record shows no muscle atrophy, no locking, no deformity, and no instability. The veteran has testified as to periodic recurrent pain and swelling with prolonged standing or walking, especially while performing her job in a computer warehouse. However, the medical evidence does not demonstrate that a higher evaluation for the left knee is warranted based on 38 C.F.R. §§ 4.40 or 4.45. Further, the left knee disability apparently has not prevented the veteran from gainful employment. In addition, there is nothing in the medical evidence that suggests that gainful employment is precluded due to her service-connected left knee disorder. Thus, there does not seem to be functional loss which would warrant a left knee rating higher than the current disability evaluations. B. Epigastric ventral hernia (previously umbilical hernia) Historically, the veteran was noted in service in November 1989 to complain of a painful "lump" over the mid-line; physical examination revealed a 1 cm. tender soft nonreducible mass and the assessment was hernia. VA examination in September 1992 noted a mild umbilical hernia on strain but no other abnormality. Subsequently the RO, by rating decision dated April 1993, granted service connection for umbilical hernia and assigned a noncompensable evaluation under the criteria of Diagnostic Code 7339. VA general surgery clinic note, dated November 1994, noted complaint of tender mass midline epigastrium. Physical examination revealed a pea-sized tender, soft mass with pinpoint fascial defect. The impression was "tiny epigastric fascial defect". The veteran was to return in January 1995 to schedule surgical repair. Another general surgery clinic note, dated June 1995, noted the veteran denied any trouble with the hernia since the previous visit. Physical examination revealed a small bulge in epigastrium; however, the examiner could not palpate the fascial defect noted in 1994. The impression was small epigastric hernia and elective repair was recommended. VA general surgery outpatient clinic note, dated July 1996, noted complaint of "stinking" and discomfort from epigastric hernia. The impression was small midline epigastric hernia and outpatient hernia repair was recommended. Report of VA examination, conducted in September 1996, noted that the veteran's primary concerns were her knees, eyes and left hand. However, she also had a small hernia in the epigastrium. The examiner noted that this had been previously described as an umbilical hernia, but actually the location was consistent with a small ventral hernia. It was further noted that the veteran denied any problem with the hernia becoming hard or firm or nonreducible, although, surgery had been suggested to her. Report of VA examination, conducted in May 1997, noted history of small protrusion above the umbilicus, most consistent with a small epigastric, freely-reducible hernia, which is never incarcerated. Physical examination revealed no umbilical hernia; however, while seated erect, a small epigastric ventral hernia was noted which was freely reducible. There was no other abnormality noted within the abdomen. The diagnosis was freely reducible, small epigastric ventral hernia. During her October video hearing, the veteran testified that she had never scheduled the hernia repair because it would require her to take off work for six weeks. She also denied the use of a truss or support. She further testified that she does, in fact, have problems with the hernia. When she is at work, the hernia will get sore, hard, and large and she worries that it will rupture. Then she stops working until it "goes down". However, when she is seen by the VA doctors it is always small again. Under 38 C.F.R. § 4.115, Diagnostic Code 7339 (1999) by which ventral hernias are evaluated, a noncompensable evaluation is assigned where there are healed postoperative wounds with no disability, and where use of a support belt is not indicated. A 20 percent evaluation is warranted where there is a small ventral hernia which is not well supported by a belt under ordinary conditions, or a healed ventral hernia or post- operative wounds with weakening of the abdominal wall and indication of a support belt. A 40 percent evaluation is contemplated for a showing of a large ventral hernia which is not well supported by a belt under ordinary conditions. Lastly, a 100 percent evaluation is assigned for a massive, persistent ventral hernia where there is severe diastasis of recti muscles or extensive diffuse destruction of weakening of muscular and fascial support of the abdominal wall so as to be inoperable. Id. In this case, the veteran's statements and testimony notwithstanding, the objective medical evidence fails to show that her ventral hernia is symptomatic at this time. The evidence does not show, and she has not reported, that she is required to wear a support belt for this disability. Furthermore, it is noted that the VA examination reports have consistently reported the veteran's denial of any symptomatology. Accordingly, the Board must conclude that assignment of a compensable evaluation for the veteran's ventral hernia is not warranted at this time, and that her claim for an increased evaluation must be denied. Because there is not an approximate balance of positive and negative evidence regarding the merits of the veteran's claim that would give rise to reasonable doubt in her favor, the provisions of 38 U.S.C.A. § 5107 are not applicable. Should the veteran's disability picture change, she may apply at any time for an increase in her assigned disability rating. See 38 C.F.R. § 4.1. At present, however, the Board finds no basis upon which to grant an increased evaluation for the veteran's epigastric ventral hernia. C. Migraine headaches Historically the veteran was diagnosed and treated for migraine/tension headaches in service from 1980 until her discharge in 1990. On VA examination in September 1992, the veteran complained of headaches of approximately three hours duration, twice a week. Neurological findings were normal and the diagnosis was migraine headaches. By rating decision dated April 1993, the RO awarded service connection for migraine headaches and assigned a 10 percent disability rating under the criteria of Diagnostic Code 8100. The veteran testified during a personal hearing conducted before a hearing officer at the RO in August 1996, that she continued to have headaches about two times a week. The severity of the headaches required her to sit down and to take Tylenol. However, these headaches were not as severe or frequent as in the military when she had to take injections for headaches. Report of VA neurological examination, conducted in September 1996, noted that the veteran complained of headaches, of 1 to 3 hour duration, and sometimes lasting all day. However, they were not as severe as in the military. Neurological finding were normal; the diagnosis was migraine syndrome. Report of VA general medical examination conducted in May 1997, noted periodic headaches as noted in the previous September 1996 examination consistent with migraine syndrome. It was reported that the headaches occur at varying intervals and last generally less than a day, but occasionally slightly longer. Neurological findings were normal. The diagnosis was migraine syndrome and/or mixed migraine-tension headaches. The veteran presented testimony at the October 1999 video hearing before the undersigned, at to the frequency of her current headaches. She stated that she was currently experiencing headaches about three times a week of one-day duration. She took Motrin, 800 mg., for the headaches. When she experienced a headache at work she would just sit at her desk until it started to fade away. The veteran's headaches are rated under Diagnostic Code 8100 for migraine which provides that migraine headaches, with characteristic prostrating attacks averaging one in 2 months over several months warrant a 10 percent evaluation. With characteristic prostrating attacks occurring on an average of one a month over the last several months warrant a 30 percent evaluation. A 50 percent evaluation, the highest possible, is warranted with "very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability." 38 C.F.R. Part 4, DC 8100 (1999). In sum, the applicable rating criteria link the ratings for migraine headaches to two elements: severity and frequency. It is not sufficient to demonstrate the existence of a particular frequency of headaches; the headaches must be of a specific prostrating character. The RO evaluated the veteran's migraine headaches as 10 percent disabling largely based on her service medical records which revealed headaches of such severity as to require medical treatment and injections. Since service, she has consistently reported during VA examinations that her headaches are not as severe as they were in service. There is no indication that current headaches include symptoms of nausea and/or vomiting. Furthermore, the veteran has indicated that her headaches do not cause her to miss work; rather, she testified in October 1999, that she continues to work, and merely takes Motrin and sits down until the headache fades away. The Board does not doubt that the veteran has a significant headache disorder productive of disability classified as migraine headaches. Nor does the Board doubt the good faith of the veteran's belief that her service connected disability warrants an increased rating under the controlling rating criteria as she interprets them. After a review of the complete record, however, the Board must conclude that the facts of this case simply do not support an increased rating. In essence, the clinical evidence, the appellant's own description of her symptoms and the competent medical evidence of record do not demonstrate the presence of migraine headaches productive of prostrating attacks of the frequency required to support a rating in excess of 10 percent. In light of the evidence of record, it is clear that the veteran does not have characteristic prostrating attacks occurring on an average of one a month over the last several months, much less "very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability." Therefore, the record does not show that the claimant's disability produces manifestations that meet or more nearly approximate the criteria for a rating in excess of the compensation award currently in effect. As such, the evidence presented does not warrant a rating in excess of 10 percent. In this regard, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but the negative evidence is not in a state of equipoise with the positive evidence to otherwise provide a basis for a more favorable resolution of this question. ORDER Service connection for bilateral carpal tunnel syndrome is denied. An increased rating for chondromalacia of the left knee is denied. An increased rating for migraine headaches is denied. A compensable evaluation for epigastric ventral hernia is denied. C. P. RUSSELL Member, Board of Veterans' Appeals