Citation Nr: 0005517 Decision Date: 02/29/00 Archive Date: 03/07/00 DOCKET NO. 96-38 184 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to an increased rating for a left knee disability with degenerative arthritis, currently rated as 20 percent disabling. 2. Entitlement to an increased initial rating for a right knee disability with degenerative arthritis, currently rated as 10 percent disabling. 3. Entitlement to service connection for a lower back disability. REPRESENTATION Appellant represented by: AMVETS WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Thomas D. Jones, Associate Counsel INTRODUCTION The veteran served on active duty from December 1942 to December 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1996 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the veteran's claim for a compensable rating for his service connected left knee disability. The veteran filed a timely notice of disagreement, and was sent a statement of the case. He responded with a timely substantive appeal. A personal hearing on this matter was afforded the veteran in December 1996. The veteran has subsequently been granted an increased rating, to 20 percent, for his left knee disability; however, because this amount does not represent the maximum available rating, and the veteran has not otherwise limited his appeal, this issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). Also, in an October 1997 hearing officer's decision, the veteran was granted service connection, with a 10 percent rating, for a right knee disability, and was denied service connection for a lower back disability. The veteran filed a timely notice of disagreement concerning these issues and was sent a statement of the case. He responded with a timely substantive appeal, and was afforded a June 1997 personal hearing. These issues were subsequently merged into a single appeal. FINDINGS OF FACT 1. The veteran's left knee disability results in moderate impairment of the joint, due to recurrent subluxation and/or lateral instability. 2. The veteran's left knee disability includes degenerative arthritis of the joint, as confirmed by X-ray findings. 3. The veteran's right knee disability results in slight impairment of the joint, due to recurrent subluxation and/or lateral instability. 4. The veteran's right knee disability includes degenerative arthritis of the joint, as confirmed by X-ray findings. 5. The veteran has a current low back disability, most recently diagnosed as degenerative arthritis of the lumbosacral spine. 6. The record does not contain evidence that the veteran's current disability of the low back results from a disease or injury incurred in or aggravated by active military service. 7. The record does not contain competent medical evidence that the veteran's current disability of the low back is proximately due to or results from a service connected disability. CONCLUSIONS OF LAW 1. A separate additional disability rating, of 10 percent, for degenerative arthritis, is warranted for the veteran's disability of the left knee. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.14, 4.20, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5256- 5263 (1999); VAOPGCPREC. 23-97 (July 1, 1997). 2. A separate additional disability rating, of 10 percent, for degenerative arthritis, is warranted for the veteran's disability of the right knee. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.14, 4.20, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5256-5263 (1999); VAOPGCPREC. 23-97 (July 1, 1997). 3. The veteran's claim for service connection for a low back disability must be denied as not well grounded. 38 U.S.C.A. §§ 1110, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.304, 3.310 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Background According to the veteran's service medical records, he was without any abnormality of the low back at the time he entered active military service in December 1942. His in- service treatment records are likewise without any diagnosis of or treatment for a low back disease or injury. At the time of his December 1945 service separation medical examination, no musculoskeletal defects of the low back were noted. In December 1995, the veteran filed a claim for an increased (compensable) rating for a service connected left knee disability. A VA medical examination was afforded him in April 1996. He reported recurrent pain of the left knee, especially with use. He has had only one episode of joint swelling. Upon objective examination, the left knee displayed full range of motion, without effusion or tenderness. No crepitus was noted. A left knee strain was diagnosed. Based on the examination results, the RO issued a May 1996 rating decision continuing the veteran's noncompensable rating for his service connected left knee disability. He responded with an August 1996 notice of disagreement, and was sent a statement of the case that same month. He then filed an August 1996 VA Form 9, perfecting his appeal. A personal hearing was also requested by the veteran. Another VA medical examination was afforded the veteran in November 1996. He reported recurrent pain of the left knee which is exacerbated by use. Upon objective examination, some left knee effusion was noted, along with mild tenderness. No instability of the joint was observed. Flexion was limited to 145º, but extension was full. X-ray examination of the left knee revealed degenerative joint disease, and this was the final diagnosis. A personal hearing at the RO was afforded the veteran in December 1996. He described the chronic pain in his left knee which limits the distance he can walk. He also has difficulty ascending stairs. At times the knee swells, and he must frequently rest after using the joint. The RO hearing officer considered this additional evidence and awarded the veteran an increased rating, to 10 percent, for his service connected disability. Another personal hearing at the RO was afforded the veteran in June 1997. He again reported chronic pain of the left knee. The pain is aggravated by use, and at times he must lay down to take weight off the joint and relieve the pain. He's been given an orthopedic brace for the left knee by the VA, but this brace does not completely alleviate the pain. He also testified that excessive wear has been placed on the right knee due to his favoring of the left knee, and he has developed low back pain secondary to his painful knees. Service connection for both these disabilities was requested. A new VA medical examination was afforded the veteran in July 1997. He reported pain in the left knee, with occasional episodes of locking. He was able to ambulate on his own, albeit with a slight limp. He used a double-hinged brace on the left knee. Upon objective physical evaluation, the veteran had extension of the left knee to 0º, and flexion to 140º. Some atrophy of the left quadriceps muscle was noted, and effusion was 1+. Joint tenderness was also present. The anterior cruciate ligament of the left knee appeared tight. The veteran's right knee range of motion revealed 0º extension and 140º flexion. No atrophy was present in the right quadriceps muscles, and no effusion was noted. Patella test was positive bilaterally. The ligaments of the right knee were within normal limits. The VA examiner diagnosed internal derangement, chondromalacia, and degenerative joint disease of the left knee. Chondromalacia of the right knee was also diagnosed, along with internal derangement, osteoarthritis, and evidence of a torn medial meniscus. The examiner suggested the disabilities of the right knee were secondary to the veteran's service connected left knee disabilities. The veteran returned for VA evaluation in September 1997. At that time, he reported low back pain of many years' duration. X-rays confirmed disc space narrowing and osteoarthritis of the lumbosacral spine. Based on the new medical evidence of record, the RO issued an October 1997 rating decision in which the veteran was awarded an increased rating, to 20 percent, for his service connected left knee disability. The RO also awarded the veteran service connection, with a 10 percent initial rating, for a right knee disability, to include degenerative arthritis, as secondary to the veteran's left knee disability. Service connection for a low back disability was denied. The veteran filed a notice of disagreement in October 1998 regarding the denial of service connection for a low back disability, and the award of a 10 percent initial rating for his right knee disability. He was sent a statement of the case, and filed a timely substantive appeal, perfecting an appeal of these issues. The veteran's appeal was initially presented to the Board in February 1999, at which time it was remanded for additional development. A new VA orthopedic examination was afforded the veteran in March 1999. At that time, he reported pain and stiffness, especially upon standing or walking, of both knees. No instability, swelling, or locking of either joint was noted. Neither joint was noted to "give way." He uses an orthopedic brace on the left knee, and usually uses one on the right as well, but was not doing so at the time of examination as it aggravated a surgical scar on his right thigh. The veteran has not had surgery on either knee, however. Upon physical examination, both knees exhibited a mild varus deformity and joint tenderness, but neither displayed any effusion. Bilateral knee ligaments were intact. McMurray and patella grind testing was negative bilaterally. Strength of the knee joints was 5/5 bilaterally, with full sensation. Right knee range of motion was 0º extension, and 120º flexion, with no subluxation noted. Left knee range of motion was 0º extension, and 120º flexion. The veteran's gait was normal, and he could heel and toe walk. The veteran is generally able to ambulate on his own, as well as drive a car. No additional functional impairment of either knee due to fatigability, lack of endurance, or episodic pain on use was noted. X-rays of the knees revealed degenerative arthritic changes bilaterally. Regarding his low back, the veteran reported chronic pain of 10-15 years duration. X-rays revealed disc space narrowing and degenerative arthritic changes of the lumbosacral spine. After reviewing the medical record and examining the veteran, the VA medical examiner stated that the veteran's low back pain due to arthritic changes was not "in any way related to the service connected bilateral knee disabilities." Analysis I. Increased rating - Left knee disability The veteran's claim for an increased rating for his service- connected left knee disability, to include degenerative arthritis, is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). The U. S. Court of Appeals for Veterans Claims (Court) has held that if a veteran claims that a service connected disability has become worse, then the claim is well grounded. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Disability evaluations are based upon the average impairment of earning capacity as contemplated by the schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (West 1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the veteran. 38 C.F.R. § 4.3 (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. 38 C.F.R. § 4.7 (1999). Regarding increased-rating claims for musculoskeletal disabilities, the Court has expounded on the necessary evidence required for a full evaluation of orthopedic disabilities. In DeLuca v. Brown, 8 Vet. App. 202 (1995), the Court held that ratings based on limitation of motion do not subsume 38 C.F.R. § 4.40 or 38 C.F.R. § 4.45. It was also held that the provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use. In the present case, the veteran's left knee disability is rated as 20 percent disabling under Diagnostic Code 5257, for other impairment of the knee. Diagnostic Code 5257 provides for disability ratings based on the degree of recurrent subluxation or lateral instability of the knee joint. Under this code, slight impairment warrants a 10 percent rating, moderate impairment, 20 percent, and severe impairment, 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1999). For the reasons to be discussed below, the preponderance of the evidence is against an increased rating, in excess of 20 percent, for the veteran's service connected left knee disability. However, a separate rating for the veteran's degenerative arthritis of the left knee is warranted in the present case. Beginning with the April 1996 VA medical examination, the veteran's left knee does not demonstrate recurrent subluxation or lateral instability equal to a severe degree of impairment. At that time, his left knee displayed full range of motion, without effusion or tenderness. When seen again in November 1996, some left knee effusion and mild tenderness was noted, but no instability of the joint was present. The July 1997 VA medical examination report confirms 1+ effusion of the left knee, and the anterior cruciate ligament appeared tight, but the veteran was able to ambulate on his own. He used an orthopedic brace on the left knee. No lateral instability or recurrent subluxation was noted in the examination report. Internal derangement of the left knee was the final diagnosis. A final VA examination was afforded the veteran in February 1999, and he was again without instability, swelling, or locking of the joint. His left knee ligaments were intact. Joint strength was 5/5, without any loss of sensation. He could walk on his own, albeit using an orthopedic brace. Overall, the medical evidence of record is against a finding of severe impairment of the left knee due to lateral instability or recurrent subluxation; thus, an increased rating, in excess of 20 percent, for the veteran's left knee disability under Diagnostic Code 5257 is not warranted. Consideration must be given to other diagnostic codes which may be applicable to the veteran's service connected knee disability. See 38 C.F.R. § 4.20 (1999). Limitation of motion of the knee will result in a compensable rating of 10 percent where extension is limited to 10º, or flexion is limited to 45º. A 20 percent rating will be awarded for extension limited to 15º, or flexion limited to 30º. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (1999). However, based on the evidence of record, an increased rating, in excess of 20 percent, for limitation of motion is not demonstrated. The most severe limitation of motion of the left knee noted in the record is quantified as 0º extension and 120º flexion, both observed in February 1999. Neither of these results warrants a compensable rating in light of the applicable diagnostic codes. Review of the remainder of the rating criteria for knee disabilities does not reveal any analogous diagnostic codes which would afford the veteran a disability rating in excess of 20 percent for his left knee disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5256-5263 (1999). Nevertheless, the VA's General Counsel (GC) has determined that because the rating criteria for arthritis do not take into consideration all possible impairment of the affected joint, separate and additional ratings may be awarded for service connected knee joints which display both lateral instability or recurrent subluxation and arthritis. 38 U.S.C.A. § 7104(c) (West 1991 & Supp. 1999); 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1999); VAOPGCPREC. 23-97 (July 1, 1997). Because these manifestations are not considered within the context of Diagnostic Code 5003 et seq., a separate award under Diagnostic Code 5257 is not in violation of 38 C.F.R. § 4.14. In the present case, the veteran's service connected left knee disability, as characterized by the RO, includes degenerative arthritis of the joint, verified by X-ray evidence. Therefore, a separate rating for arthritis of the left knee may be awarded under the law, in light of the aforementioned GC opinion. Degenerative arthritis is rated under Diagnostic Code 5003, which in turn makes reference to any limitation of motion of the affected joint. When the limitation of motion of the affected joint is noncompensable under the appropriate diagnostic code, a rating of 10 percent is applied for each major joint or group of minor joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (1999). As is discussed above, the veteran's limitation of motion of the left knee is noncompensable; thus, a separate 10 percent disability rating, and no higher, is warranted for degenerative arthritis of the left knee. As noted by the Court in DeLuca, there are situations in which the application of 38 C.F.R. §§ 4.40, 4.45, or 4.59 is warranted in order to evaluate the existence of any functional loss due to pain, or any weakened movement, excess fatigability, incoordination, or pain on movement of the veteran's joints when the rating code under which the veteran is rated does not contemplate these factors. See DeLuca, supra). The veteran has complained of these impairments at his personal hearings, and stated his mobility is limited as a result. However, various medical examiners have been unable to quantify these factors in terms of additional degrees of disability or limitation of motion of the left knee, and any such speculation by the Board is strictly prohibited. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). In view of this finding, an increased rating based on these factors does not appear justified. Likewise, a review of the medical evidence does not reflect objective evidence of pain greater than that contemplated by the current rating. Thus, 38 C.F.R. §§ 4.40, 4.45 or 4.59 do not provide a basis for a higher rating when considering DeLuca factors. Consideration has also been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they were raised by the veteran. The evidence discussed herein does not show that the service connected disability at issue presents such an unusual or exceptional disability picture as to render impractical the application of the regular schedular standards. In particular, the veteran's left knee disability has itself required no periods of hospitalization since his service separation, and is not shown by the evidence to present marked interference with employment in and of itself, as the veteran is retired from active employment. Therefore, the assignment of an extraschedular evaluation under 38 C.F.R. § 3.321(b) is not warranted at this time. The veteran has not otherwise submitted evidence tending to show that his service-connected left knee disability is unusual, or causes marked interference with work other than as contemplated within the schedular provisions discussed herein. In conclusion, the preponderance of the evidence is against an increased rating, in excess of 20 percent, for the veteran's service connected left knee disability, under Diagnostic Code 5257, or any other diagnostic codes for the knee. However, a separate additional disability rating of 10 percent is warranted for the veteran's degenerative arthritis of the left knee, as confirmed by X-ray evidence. II. Increased initial rating - Right knee disability The veteran's claim for an increased initial rating for his service-connected right knee disability is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). The U. S. Court of Appeals for Veterans Claims (Court) has held that if a veteran claims that a service connected disability has become worse, then the claim is well grounded. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Disability evaluations are assigned by applying a schedule of ratings which represent, as far as can practicably be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When the assignment of initial ratings is under consideration, the level of disability in all periods since the effective date of the grant of service connection must be taken into account. Fenderson v. West, 12 Vet. App. 119 (1998). Currently, the veteran's right knee disability is rated as 10 percent disabling under Diagnostic Code 5257, for other impairment of the knee. Diagnostic Code 5257 provides for disability ratings based on the degree of recurrent subluxation or lateral instability of the knee joint. Under this code, slight impairment warrants a 10 percent rating, moderate impairment, 20 percent, and severe impairment, 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1999). For the reasons to be discussed below, the preponderance of the evidence is against an increased initial rating, in excess of 10 percent, for the veteran's service connected right knee disability. However, a separate rating for the veteran's degenerative arthritis of the right knee is warranted in the present case. The veteran's right knee was first medically evaluated by the VA in July 1997, at which time it was without effusion or muscular atrophy. The ligaments were all intact; however a patella test was positive. Range of motion testing revealed 0º extension and 140º flexion. When he was evaluated again in February 1999, the right knee joint was again without effusion or subluxation, and joint strength was 5/5. No instability was noted. All right knee ligaments were intact, and McMurray and patella grind testing was negative. Range of motion testing revealed extension to 0º and flexion to 120º. X-ray evaluation confirmed degenerative arthritis of the right knee. Overall, the medical evidence of record is against a finding of moderate impairment of the right knee due to lateral instability or recurrent subluxation; thus, an increased initial rating, in excess of 10 percent, for the veteran's right knee disability under Diagnostic Code 5257 is not warranted. Consideration must also be given to other diagnostic codes which may be applicable to the veteran's service connected knee disability. See 38 C.F.R. § 4.20 (1999). While knee joint disabilities may be rated based on limitation of motion, the evidence currently of record, does not support a compensable rating for limitation of motion. The most severe limitation of motion of the right knee noted in the record is quantified as 0º extension and 120º flexion, both observed in February 1999. Neither of these results warrants a compensable rating in light of the applicable diagnostic codes. Review of the remainder of the rating criteria for knee disabilities does not reveal any analogous diagnostic codes which would afford the veteran an initial disability rating in excess of 10 percent for his right knee disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5256-5263 (1999). Nevertheless, a separate rating for degenerative arthritis of the right knee, as with the left knee, is warranted. 38 U.S.C.A. § 7104(c) (West 1991 & Supp. 1999); 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1999); VAOPGCPREC. 23-97 (July 1, 1997). The veteran's service connected right knee disability, as characterized by the RO, includes degenerative arthritis of the joint, verified by X-ray evidence. Therefore, a separate initial rating for arthritis of the right knee may be awarded under the law, in light of the aforementioned GC opinion. Degenerative arthritis is rated under Diagnostic Code 5003, which in turn makes reference to any limitation of motion of the affected joint. When the limitation of motion of the affected joint is noncompensable under the appropriate diagnostic code, a rating of 10 percent is applied for each major joint or group of minor joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (1999). As is discussed above, the veteran's limitation of motion of the right knee is noncompensable; thus, a separate 10 percent disability rating, and no higher, is warranted for degenerative arthritis of the right knee. As noted by the Court in DeLuca, there are situations in which the application of 38 C.F.R. §§ 4.40, 4.45, or 4.59 is warranted in order to evaluate the existence of any functional loss due to pain, or any weakened movement, excess fatigability, incoordination, or pain on movement of the veteran's joints when the rating code under which the veteran is rated does not contemplate these factors. See DeLuca, supra). The veteran has complained of these impairments at his personal hearings, and stated his mobility is limited as a result. However, various medical examiners have been unable to quantify these factors in terms of additional degrees of disability or limitation of motion of the right knee, and any such speculation by the Board is strictly prohibited. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). In view of this finding, an increased initial rating based on these factors does not appear justified. Likewise, a review of the medical evidence does not reflect objective evidence of pain greater than that contemplated by the current rating. Thus, 38 C.F.R. §§ 4.40, 4.45 or 4.59 do not provide a basis for a higher initial rating when considering DeLuca factors. A review of the evidence does not suggest the veteran is entitled to a "staged" rating for his service-connected disability, as prescribed by the Court in Fenderson v. West, 12 Vet. App. 119 (1999). At no time since the veteran filed his claim for service connection has the service connected disability been more disabling than as currently rated. The veteran's impairment of the right knee has, however, presented a degree of impairment equal to a 10 percent rating under Diagnostic Code 5257, and a separate rating of 10 percent under Diagnostic Code 5003, since the effective date of the claim. Consideration has also been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they were raised by the veteran. The evidence discussed herein does not show that the service connected disability at issue presents such an unusual or exceptional disability picture as to render impractical the application of the regular schedular standards. In particular, the veteran's right knee disability has itself required no periods of hospitalization since the award of service connection, and is not shown by the evidence to present marked interference with employment in and of itself, as the veteran is retired from active employment. Therefore, the assignment of an extraschedular evaluation under 38 C.F.R. § 3.321(b) is not warranted at this time. The veteran has not otherwise submitted evidence tending to show that his service-connected right knee disability is unusual, or causes marked interference with work other than as contemplated within the schedular provisions discussed herein. In conclusion, the preponderance of the evidence is against an increased initial rating, in excess of 10 percent, for the veteran's service connected right knee disability, under Diagnostic Code 5257, or any other diagnostic codes for the knee. However, a separate additional disability rating of 10 percent is warranted for the veteran's degenerative arthritis of the right knee, as confirmed by X-ray evidence. III. Service connection - Low back disability The veteran seeks service connection for a low back disability, which he alleges is secondary to his service connected left knee disability. Service connection will be awarded for any disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). Service connection is also warranted for a disability which is proximately due to or the result of a service connected disability. 38 C.F.R. § 3.310 (1999). As with all benefit claims, when an approximate balance exists between the positive and negative evidence regarding the matter at issue, the benefit of the doubt shall be granted the claimant. 38 U.S.C.A. § 5107(b) (West 1991). However, the preliminary requirement for establishing entitlement to any VA benefit is that the applicant submit a claim which is sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). The U. S. Court of Appeals for Veterans Claims (Court) has defined a well- grounded claim as "a plausible claim, one which is meritorious on its own or capable of substantiation." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Such a claim need not be conclusive, but only possible, to satisfy the initial burden of § 5107. Id. Case law promulgated by the Court has resulted in what is in effect a three pronged test to determine whether a claim is well grounded. There must be competent evidence of a current disability (medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the injury or disease in service and the current disability (medical evidence). See Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Grottveit v. Brown, 5 Vet. App. 92 (1993); Grivois v. Brown, 6 Vet. App. 136 (1994); Caluza v. Brown, 7 Vet. App. 498 (1995). To be well grounded, a claim must be supported by evidence that suggests more than a purely speculative basis for an award of benefits; evidence is required, not just allegations. Tirpak v. Derwinski, 2 Vet. App. 609 (1992); Dixon v. Derwinski, 3 Vet. App. 261 (1992). For the reasons to be discussed below, the veteran's claim for service connection for a low back disability is not well grounded, and must be denied on that basis. Service connection for a low back disability is not warranted on a direct basis, as no evidence exists in the service medical records, or any other record, of an in-service disease or injury to the low back which has resulted in a current disability, and the veteran does not so allege. Rather, his sole contention is that his service connected bilateral knee disabilities have caused or aggravated a low back disability; if true, service connection for a low back disability is warranted under 38 C.F.R. § 3.310 (1999). As an initial matter, the record contains a competent medical diagnosis, supported by X-ray evidence, of degenerative osteoarthritis of the lumbosacral spine. In the absence of any evidence to the contrary, a current low back disability is conceded by the Board. Nevertheless, the veteran has not submitted competent medical evidence that his current low back disability is proximately due to or resulting from a service connected disability. While he has presented his own lay assertions that his current low back disability is due to his bilateral knee disabilities, he, as a layperson, is not qualified to offer expert medical opinion evidence binding on the Board. See Pearlman v. West, 11 Vet. App. 443, 447 (1998) [citing Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992)]. The only medical evidence addressing this issue stems from the February 1999 VA medical examination report, and it suggests against the veteran's assertions. After reviewing the medical record and examining the veteran, the VA medical examiner stated that the veteran's low back pain due to arthritic changes was not "in any way related to the service connected bilateral knee disabilities." In the absence of any medical evidence supporting the veteran's contention that his low back disability "is proximately due to or the result of" a service connected disability, the claim is not well grounded. 38 C.F.R. § 3.310 (1999); Anderson v. West, 12 Vet. App. 491, 496 (1999). In conclusion, the veteran's claim for service connection for a low back disability is not well grounded. The evidence does not demonstrate that his current disability results from a disease or injury incurred in or aggravated by active military service, or that it is proximately due to or results from a service connected disability. As the claim is not well grounded, it must be denied. Caluza, supra. ORDER 1. A separate additional disability rating of 10 percent is warranted for the veteran's left knee disability, to include degenerative arthritis. 2. A separate additional disability rating of 10 percent is warranted for the veteran's left knee disability, to include degenerative arthritis. 3. Service connection for a low back disability is denied. G. H. SHUFELT Member, Board of Veterans' Appeals