Citation Nr: 0308869 Decision Date: 05/09/03 Archive Date: 05/20/03 DOCKET NO. 98-08 905 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent for a left knee disability. 2. Entitlement to service connection for degenerative joint disease (DJD), left shoulder, with probable rotator cuff tear as secondary to the service connected left knee disability. 3. Entitlement to service connection for degenerative changes, lumbar spine, to include as secondary to the service connected left knee disability. 4. Entitlement to service connection for degenerative changes, cervical spine, to include as secondary to the service connected left knee disability. 5. Entitlement to service connection for degenerative arthritis, right ankle, to include as secondary to the service connected left knee disability. 6. Entitlement to service connection for degenerative arthritis, left ankle, to include as secondary to the service connected left knee disability. 7. Entitlement to special monthly pension by reason of the need for aid and attendance of another person or at the housebound rate. (A legal issue is addressed in a separate decision.) REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Stanley Grabia, Counsel INTRODUCTION The veteran served on active duty from January 1953 to June 1954. This matter came before the Board of Veterans' Appeals (Board) from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi that denied the veteran's claims for an increased evaluation for his service-connected left knee disability, and service connection for: DJD, left shoulder: degenerative changes, lumbar spine, and cervical spine; and degenerative arthritis, right and left ankle all claimed as secondary to the service connected left knee disability. In addition, the RO denied entitlement to a special monthly pension by reason of the need for aid and attendance of another person or at the housebound rate. The veteran testified at personal hearings at the RO in March and October 1998 and also at a Videoconference hearing in November 1999, which was chaired by the undersigned. Transcripts of these hearings are in the file. In January 2000, the Board remanded this case for additional development to include obtaining both private and VA treatment records. That development has been completed and the case has been returned to the Board for further consideration of the veteran's appeal. In a VA Form 21-438, Statement of the Case, dated in September 2002, the veteran canceled all hearing requests outstanding at that time. FINDINGS OF FACT 1. VA has made all reasonable efforts to assist the veteran in the development of his claims and has notified him of the information and evidence necessary to substantiate his claims. 2. The veteran currently has one service-connected disability: a left knee disorder, evaluated as 30 percent disabling. 3. The veteran's left knee disorder is manifested by extension limited to no more than 20 degrees; neither ankylosis of the knee nor limitation of extension to 30 degrees has been shown. 4. There is no medical nexus evidence of record indicating the degenerative joint disease (DJD), left shoulder is etiologically related to the veteran's service in the military, or to his service-connected left knee disability. 5. There is no medical nexus evidence of record indicating degenerative changes, lumbar spine are etiologically related to the veteran's service in the military, or to his service- connected left knee disability. 6. There is no medical nexus evidence of record indicating degenerative changes, cervical spine are etiologically related to the veteran's service in the military, or to his service-connected left knee disability. 7. There is no medical nexus evidence of record indicating the degenerative arthritis, right ankle is etiologically related to the veteran's service in the military, or to his service-connected left knee disability. 8. There is no medical nexus evidence of record indicating the degenerative arthritis, left ankle is etiologically related to the veteran's service in the military, or to his service-connected left knee disability. 9. The medical evidence shows no anatomical loss or loss of use of both feet, or of one hand and one foot. 10. The veteran's disabilities render him unable to care for most of his daily needs without requiring aid and attendance (A&A). 11. The veteran's service-connected disability does do not render him factually unable to leave his home, and he is not housebound in fact. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for a left knee disorder based on arthritis with limitation of motion are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4, Diagnostic Codes 5010-5261 (2002). 2. Degenerative joint disease (DJD), left shoulder was not incurred in or aggravated by the veteran's active military service, nor is it the result of a service connected condition. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2002). 3. Degenerative changes, lumbar spine was not incurred in or aggravated by the veteran's active military service, nor is it the result of a service connected condition. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2002). 4. Degenerative changes, cervical spine was not incurred in or aggravated by the veteran's active military service, nor is it the result of a service connected condition. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2002). 5. Degenerative arthritis, right ankle was not incurred in or aggravated by the veteran's active military service, nor is it the result of a service connected condition. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2002). 6. Degenerative arthritis, left ankle was not incurred in or aggravated by the veteran's active military service, nor is it the result of a service connected condition. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2002). 7. The criteria for an award of SMP based on A&A have been met. 38 U.S.C.A. §§ 1502, 1521, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), 3.350, 3.351, 3.352 (2002). 8. The criteria for an award of SMP based on housebound status have not been met. 38 U.S.C.A. §§ 1502, 1521, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), 3.350, 3.351, 3.352 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a preliminary matter, the Board observes that VA has a duty to assist in the development of facts pertinent to the veteran's claims. On November 9, 2000, the Veterans Claims Assistance Act of 2000, 114 Stat. 2096 (2000) (VCAA), now codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002), went into effect. VA has promulgated revised regulations to implement these changes in the law. 38 C.F.R §§ 3.102, 3.156(a), 3.159 and 3.326(a)(2002). In this case, VA's duties have been fulfilled to the extent possible. VA must notify the veteran of evidence and information necessary to substantiate his claims and inform him whether he or VA bears the burden of producing or obtaining that evidence or information. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The veteran was notified of the information necessary to substantiate his claims and which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf by means of letters in March and August 2001; the discussion in the April 1998, February 1999, October 2001, and April 2002 rating decisions; by the Board Remand in January 2000; the June 1998, May 2001, and April 2002 statements of the case; and the February 1999, June 2001, April 2002, and August 2002 supplemental statements of the case. VA must also make reasonable efforts to assist the veteran in obtaining evidence necessary to substantiate the claims for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A(a) (West 2002); 38 C.F.R. § 3.159(c), (d). The duty to assist also includes obtaining records of relevant treatment at VA facilities, and any other relevant records held by any Federal department or agency identified by the veteran. If VA is unable to obtain records identified by the veteran, VA must notify him of the identity of the records that were not obtained, explain the efforts taken to obtain the records, and describe any further action to be taken. The Board finds that VA has met its duty to assist the veteran in the development of his claims under the VCAA. The veteran has been afforded examinations by VA in October/November 1997, November 1998, December 2001, and May 2002 addressing the disabilities on appeal. Service, VA and private outpatient and hospital treatment records have been associated with the claims file. There does not appear to be any outstanding medical records that are relevant to this appeal. As noted the claims were remanded by the Board in January 2000 for additional development which has been accomplished. This included obtaining private and VA hospital treatment records. The Board further notes that the veteran had the opportunity to testify at personal hearings in March and October1998 at the RO. In addition he testified at a Videoconference hearings in November 1999. The VA has satisfied its duties to notify and assist the veteran. I. Background. Service records reveal that the veteran injured his left knee in a motor scooter accident in 1948 prior to service. He received a direct blow causing the knee to swell for several weeks. Subsequently he reinjured the knee with a twisting strain while playing football, also prior to service. He continued to play football and reinjured the knee and fractured his right ankle in 1952. He has had frequent locking episodes and soreness with prolonged walking since that time. He continued to complain and receive treatment for his left knee disorder during service. In a medical review board in May 1954 it was noted that x-rays of his left knee were normal. However the examination revealed multiple ligament relaxation in the left knee due to repeated knee injuries suffered while playing football prior to service. Locking episodes were relieved by a medial meniscectomy in July 1953. The board noted the veteran could subluxate the left knee at will. In the opinion of the board he was unfit for continued service and he was subsequently separated from service. The veteran filed a claim for service connection for a left knee disorder in March 1981. By rating action in April 1981 service connection was denied as the knee disorder preexisted service and was not aggravated in service. The veteran filed to reopen his claim for service connection for his left knee disorder in September 1997. In addition he claimed a low back, shoulder, neck and ankle disorders. In October and November 1997, the veteran underwent a VA examination. At that time, he reported that he had hurt his left knee playing football in 1953. He was treated in service and underwent surgery for a cartilage tear in January or February 1954. He was discharged because of his left knee in June 1954. He continued playing football at the University of Arizona and played professional football for a couple of years after that. He reported that his left knee was painful and pops. He stated that he could not walk or climb. His right knee also locked up at times, and popped but not as much as his left knee. Regarding his left shoulder, it became painful and developed limited motion about 3 years prior without any actual trauma. His neck has bothered him for the last 8 years and he took 800 mg of Motrin 3x daily for this. He stated that his ankles were worn out. They popped and swelled some but did not hurt a lot. He took a variety of medications for cholesterol, hypertension, and arthritis. He has not worked in the last 8 years because he could not climb ladders. On examination, the veteran walked with a mild antalgic gait on the left. There was also a mild genus varus on the left. He could heel and toe walk and do a 1/5 squat. There was a 5-inch medial scar healed and not bound down over the anterior aspect of his left knee. The veteran's neck was held in about a 25 degree position of forward flexion. This was a normal posture and he could flex it to a position of 55 degrees flexion but would not hyperextend it. This meant that he had only about 30 degrees of motion of flexion in his neck. He could bend 18 degrees to the right and 13 degrees to the left. He had about 30 degrees of rotation to the right and 18 degrees to the left in his neck. He did not have biceps reflexes in either extremity but had good triceps and radial periosteal reflexes in both extremities. He had weakness in the shoulder girdle musculature on the left and the elbow flexor on the left. He had full ROM of the elbows, forearms, hands, and wrists. The left shoulder had limited ROM. He could abduct to 60 degrees to the left and 180 degrees to the right; flexion was 73 degrees and 180 degrees to the right; external rotation was 30 degrees to the left and 45 degrees to the right; internal rotation was 90 degrees on the left and right; and extension was approximately 15 degrees bilaterally. There was crepitation in the left shoulder on circumduction and it was markedly painful. The examiner could not get any significant greater ROM passively because of pain in the left shoulder. Standing, the lower back revealed 50 degrees forward flexion; 15 degrees extension and bending left and right; and, about 5 degrees of turning left and right. He was areflexic in his knees and ankles and had negative straight leg raising bilaterally. He appeared to have good strength in his long toes extensors and quadriceps muscles bilaterally. The left knee was 3/4 inch greater in circumference than the right knee. The left calf was 1/4 inch greater in circumference than the right calf. ROM in the left knee was from 10 degrees extension to 122 degrees of flexion. In other words he had 10 degree flexion contracture on the left. On the right the ROM was from 0 degrees extension to 143 degrees of flexion. The ankles measured equal in circumference but there was a 1+ pitting edema bilaterally in both legs and feet. ROM in the left ankle was 10 degrees dorsiflexion and 60 degrees of plantar flexion. In the right ankle ROM was 15 degrees dorsiflexion and 60 degrees of plantar flexion. He had approximately 10 degrees of inversion in both ankles with no eversion permissible. AP and lateral x-rays of the cervical spine showed heterotopic bone in the anterior and longitudinal ligament as well as cervical spondylosis. There was degenerative disc disease (DDD) at C5 . AP and lateral x-rays of the lumbar spine showed a markedly narrowed L4 disc interspace. There was hyperthropic spurring at the anterior aspect of all the lumbar vertebrae. There was marked wedging of the L1 and T12 vertebrae. On a non- torrid view of the cervical spine there was hyperthropic spurring between the bodies of C1 and C2. AP and lateral x-rays of the right shoulder showed marked acromioclavicular arthritis with degenerative joint space at the glenohumeral articulation, AP and lateral x-rays of the left shoulder showed marked degenerative joint disease at the glenohumeral and AC joint. The degree of arthritis was greater on the left than on the right. AP and lateral x-rays of both ankles showed spurring to the anterior aspects of the tibia and neck of the talus, and there was some heterotopic bone build up along the inferior aspect of the medial and lateral malleolus. All of this was indicative of degenerative arthritis in both ankles . AP and lateral x-rays of the right knee showed a little bit of loss of continuity of the tibial spines. There was hyperthropic spurring at the articular surface of his patella and the joint space medially was slightly narrowed. AP and lateral x-rays of the left knee showed severe degenerative arthritis with marked spurring of the femoral condyles and probable loose bodies in the back of the knee to a significant degree. There was marked narrowing of the medial joint space with about 10 degrees of genus varus in his knee. The diagnoses were: traumatic arthritis of the left knee, severe; degenerative arthritis of the right knee, ankles, and shoulders; and, hyperthropic arthritis with cervical spondylosis without myelopathy and advanced DDD with hyperthropic arthritis in the lumbar spine. The examiner noted that the veteran had looseness to both knees. He denied any actual injury to the right knee but there was some fragmentation to the lateral tibial spine in the intercondylar notch on x-ray. His left knee was going to definitively require a knee replacement in the very near future. His back and his neck could qualify to having disseminated idiopathic skeletal hyperostosis as well as the DDD. At a personal hearing in March 1998, the veteran, in essence, testified that prior to service he had a trick knee. He began having knee problems about 4 months after service and received regular treatment for the left knee pain. He underwent surgery in 1954. However his knee did not improve and he was medically discharged in June 1954. He has been treated by VA since 1961. He also received treatment from Jerry Dotson, M.D. By rating action in April 1998 service connection was granted for traumatic arthritis left knee and a 10 percent rating was assigned. In addition, service connection was denied for a left shoulder disorder, and degenerative arthritis of the lumbar spine, cervical spine, and the ankles as secondary to the arthritis of the left knee. In making that determination the RO noted there was no evidence of these disabilities in service. In a personal hearing in October 1998, the veteran, in essence, testified that he had pain and swelling in the left knee. He used a cane although it had not been prescribed for his knee disability. He was not seeing a physician for his left knee but he was taking Motrin. His knee did not give way on him but from time to time it locked up on him. He also noted left shoulder, lumbar, cervical, and ankle pain all caused by arthritis. He believed the arthritis spread from his left knee throughout his system. He was not receiving any specific treatment although he was treated when required through VA. At a November 1998 VA examination, the veteran reported that he has gotten much worse since his last examination. He complained that on a scale of 1-10 his cervical and lumbar spine pain was a 5, and during flare-ups it was an 8; his left shoulder pain was a 7, and during flare-ups 8 to 10; he could not lift his right arm at all, and it was an 8 most of the time; his ankles were usually a 6. Referring to his left knee it was a 10 all the time. He had positive pain, stiffness, instability, locking, giving way, heat and positive fatigue. He used an ace wrap when he did yard work. Every 3 to 4 days he gets to the point where he cannot walk at all and must get off it for several hours until the pain gets better. The examiner noted the veteran could not walk on his heels and toes, and only squatted slightly. Deep tendon reflexes (DTRs) could not be elicited in either ankle. Patellar DTRS were 1+ bilaterally. In the biceps region the examiner, "couldn't elicit anything." ROM in the cervical spine was 30 degrees of forward flexion, extension backwards of 5 degrees, lateral flexion right and left of 30 degrees, rotation to the right of 35 degrees and 30 degrees to the left. Lumbar spine ROM was 60 degrees of forward flexion, extension backwards of 15 degrees, lateral flexion right and left of 15 degrees, rotation to the right of 20 degrees and 25 degrees to the left. There was tenderness in the cervical and lumbar spine areas. The left arm appeared slightly weaker than the right. Left shoulder extension was 20 degrees active and 30 degrees passive; flexion 0-50 degrees active and 0-60 degrees passive; abduction was 0-50 degrees active and 0-65 degrees passive; external rotation was 0-35 degrees active and passive; and, internal rotation was 0-30 degrees active and 0-45 degrees passive. Right shoulder flexion was 0-55 degrees active and 0-75 degrees passive; abduction was 0-65 degrees active and 0-90 degrees passive; external rotation was 0-45 degrees active and 0-60 degrees passive; internal rotation was 0-30 degrees active and 0-50 degrees passive; and extension was 0-30 degrees active and passive. Examination of the ankles revealed bilateral tenderness throughout. The ankles appeared stiff with crepitus felt with motion. In the right ankle he had 0-10 degrees of dorsiflexion active and passive, and 0-15 degrees of plantar flexion active and passive. He appeared to have slightly flat feet. While he had an arch on both feet it appeared to be a 10 degree variance in lining up the Achilles tendon in both feet. Examination of the left knee revealed tenderness along the lateral aspects of the knee as well as with pressure on the patella. Flexion was 0-70 degrees active and 10-90 degrees passive; extension was -20 degrees active and -10 degrees passive. Full extension was limited in other words by 20 degrees active and 10 degrees passive. The knee appeared to be stable medial and laterally but anteriorly and posteriorly there appeared to be some laxity with greater than 5mm motion. When he ambulated, he limped because of his left leg and took short steps, kind of in a jerky motion when he walked. He appeared to have pain when stepping on that leg. While doing ROM exercises crepitation was noted upon palpation. The diagnoses was; degenerative joint disease (DJD) severe, left shoulder and left knee; DJD cervical and lumbar spine; rotator cuff injury, left shoulder; rule out chronic rotator cuff injury, right shoulder, as well as DJD by x-rays; DJD, ankles bilaterally, and right knee. In a November 1998 addendum to the VA examination it was noted that; X-rays of the left knee showed moderate osteoarthritic changes with narrowing to all 3 joint compartments, hypertrophic spurs at the distal femur, upper tibia, and posterior patella. Multiple calcified intra-articular loose bodies were seen. No joint effusion was identified. The impression was moderate degenerative changes of the knee. X-rays also revealed left shoulder degenerative changes at the AC joint with chronic rotator cuff injury; lumbar spine with moderate osteoarthritis; cervical spine revealed degenerative changes; and the ankles showed post traumatic and degenerative changes. In a Videoconference hearing in November 1999 the veteran, in essence, testified that he underwent a left knee operation in service and, I guess arthritis must have set up in it or something and it's gone all the way through my body through all my joints and I don't really know what else to say except, my shoulder, my ankle, and my back. His left knee went out maybe 4 times a day, and he used a cane and a knee brace on his left knee. The knee swells about 3 times a week and gives out about 3 or 4 times daily. He had been treated for his knee and other complaints at VA. He does not receive treatment from private physicians. The veteran also testified that he fell in service during maneuvers, going up Mt. Fuji in Japan due to his left knee. He contends that he injured his shoulder, back, neck, and ankles in that fall causing his current arthritis. He had discussed a knee replacement with his VA doctor but was told that because of his age it would be pretty hard on him. In January 2000 the Board remanded this case in order to obtain the veteran's complete VA treatment records. VA treatment records were subsequently received and are in the claims file. In a May 2002 VA examination, the examiner noted that the veteran was being evaluated for his service connected left knee disorder. He was also claiming service connection for arthritis of the left shoulder, lumbar and cervical spines, and ankles as secondary to his left knee disorder. The RO had requested a medical opinion regarding any relationships as contended by the veteran. The claims file was reviewed prior and in conjunction with the examination. The examiner noted a history of pain in the left knee with prolonged walking, standing, climbing, or twisting. It was noted that the veteran first injured his left knee in a motor scooter accident prior to service in 1948. However the veteran absolutely denied ever having a problem with his left knee prior to service. The record further contained information regarding injury to the left knee playing football. Further review of the records reveals that he fractured both ankles one in 1948 and the other in 1951. Again he denied ever fracturing the ankles. A C&P examination in November 1997 described severe traumatic arthritis of the left knee. It also described DJD right knee, ankles, and shoulders. In addition it was felt that he had hypertrophic arthritis with cervical spondylosis and advanced DDD with hypertrophic arthritis of the lumbar spine. The examiner noted that the veteran was markedly symptomatic with multiple arthritic complaints. He described pain in the areas of the neck, left shoulder, back, both ankles, and left knee. He had markedly limited physical functions secondary to problems with all of the above. He could not bend or lift, and weight bearing was said to be painful. He could only walk short distance or periods. He had been issued a motorized wheelchair and was presently installing a ramp in his house. The veteran presented in a wheelchair. He could hobble about the room stiffly and slowly. Examination of the neck revealed right and left lateral rotation 35 degrees; 45 degrees of flexion; and, 0 degrees of extension. There was pain on ROM and tenderness to palpation on the posterior midline of the neck. No spasm was noted. Left shoulder ROM was markedly limited. He demonstrated only 60 degrees of flexion, and 55 degrees abduction. He resisted further attempts at passive ROM due to pain. Internal rotation was to 30 degrees, and external rotation was 60 degrees. There was pain on all motion. He had tenderness to palpation and marked weakness of the shoulder. Examination of the back revealed no spasms but there was tenderness to palpation in the left lower lumbar region. ROM was 60 degrees of flexion, and 15 degrees of extension, and left and right lateral bending. There was pain on all ROM testing. There was a well healed surgical scar on the left knee. The knee lacked 15 degrees from terminal extension, and had 110 degrees of flexion. There was pain on motion, swelling, enlargement and tenderness of the knee. He was particularly tender over the area of the medial joint line. Lachman and anterior drawer signs were negative, although he was demonstrating some guarding secondary to pain. He was felt to have mild medial collateral ligament laxity with popping and pain noted with valgus stress applied to the knee. He had 3+ bilateral pretibial pitting edema, and also rather masked swelling of both ankles with generalized tenderness to palpations of both ankles. Both ankles had 5 degrees of dorsiflexion and 35 degrees of plantar flexion with pain on motion. Neurologically, he demonstrated generalized weakness in the left upper extremity and normal strength in the right. Reflexes were intact at the knees and absent at the ankles. Sensation to light touch was intact in the lower extremities. The impression was; severe posttraumatic arthritis, left knee postoperative; polyarthritis secondary to DJD including left shoulder and ankles, probable rotator cuff tear, left shoulder; records describe history of gout; degenerative changes cervical and lumbar spines. Regarding the veteran's pain and marked limitation of function of multiple joint under DeLuca, the examiner noted; He demonstrated pain on motion, limitation of motion, weakness as well as increased fatigability. It is not feasible, however, to express any of this in terms of additional limitation of function as these matters simply cannot be determined with any degree of medical certainty. There is no question that he had marked and severe limitations secondary to his generalized arthritic complaints. Certainly, there is a history of posttraumatic arthritis of the left knee. however, I think that the claim that the multiple areas of arthritis are 'secondary' to the service connected traumatic arthritis of the left knee are somewhat speculative in nature as opposed to rising to the level of reasonable medical certainty or even as likely as not. II. Law and Regulations. II.a. Service connection. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if preexisting such service, was aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2002). Service connection may 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 C.F.R. § 3.303(d). Secondary service connection shall be awarded when a disability is "proximately due to or the result of a service connected disease or injury. . . ." 38 C.F.R. § 3.310(a). See Libertine v. Brown, 9 Vet. App. 521, 522 (1996); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (en banc). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). II.b. Increased Ratings. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2002). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2002). However, the Board will consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2002). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2002). In evaluating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Inquiry must also made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. 38 C.F.R. § 4.59. See generally DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). In rating the service-connected left knee disability, all applicable diagnostic codes must be considered to include Diagnostic Codes 5003, 5010, 5256, 5257, 5258, 5259, 5260, 5261 and 5262. Moreover, VA General Counsel, in a precedential opinion (VAOPGCPREC 23-97), held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. The General Counsel stated that when a knee disorder was already rated under Diagnostic Code 5257, the veteran must also have limitation of motion which at least meets the criteria for a zero-percent rating under Diagnostic Code 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more) in order to obtain a separate rating for arthritis. The General Counsel subsequently held in VAOPGCPREC 9-98 that a separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59; see also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). Where additionally disability is shown, a veteran rated under Diagnostic Code 5257 can also be compensated under Diagnostic Code 5003 and vice versa. The veteran's left knee disability is currently rated as 30 percent disabling under Diagnostic Code 5010-5261. Diagnostic Code 5010, Arthritis, due to trauma, substantiated by X-ray findings is rated under Diagnostic Code 5003, for Degenerative Arthritis. Diagnostic Code 5003 establishes, essentially, three methods of evaluating degenerative arthritis which is established by x-ray studies: (1) when there is a compensable degree of limitation of motion, (2) when there is a noncompensable degree of limitation of motion, and (3) when there is no limitation of motion. Generally, when documented by x-ray studies, arthritis is rated on the basis of limitation of motion under the appropriate diagnostic code for the joint involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasms, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. Read together, Diagnostic Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by x-ray study, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no compensable limitation of motion. Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991), Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). In the absence of limitation of motion, a 10 percent disability rating is assigned under Diagnostic Code 5003 where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups, and a 20 percent disability rating is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. These 10 and 20 percent ratings based on x- ray findings will not be combined with ratings based on limitation of motion. Under Diagnostic Code 5256 for ankylosis of the knee, a 30 percent rating is assigned for ankylosis at a favorable angle in full extension, or in slight flexion between 0 and 10 degrees. A 40 percent rating is assigned for ankylosis in flexion between 10 and 20 degrees. A 50 percent rating is assigned for ankylosis in flexion between 20 and 45 degrees. A maximum 60 percent rating is assigned for extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more. Diagnostic Code 5257 provides for a 10 percent rating where there is recurrent subluxation or lateral instability of a mild degree. A moderate degree of recurrent subluxation or lateral instability warrants a 20 percent rating. A 30 percent rating is assigned where the medical evidence shows severe recurrent subluxation or instability. Under Diagnostic Code 5258, a maximum 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Under Diagnostic Code 5259, a maximum 10 percent rating is assigned for symptomatic removal of semilunar cartilage. A 10 percent evaluation on the basis of limitation of motion of the knees requires limitation of extension of the knee to 10 degrees or limitation of flexion to 45 degrees. A 20 percent evaluation requires limitation of extension to 15 degrees and limitation of flexion to 30 degrees. A 30 percent evaluation requires limitation of extension to 20 degrees and limitation of flexion to 15 degrees. Limitation of extension to 30 degrees warrants a 40 percent evaluation, while limitation of extension to 45 degrees warrants a 50 percent evaluation. Id. A maximum 30 percent rating is assigned for limitation of flexion of the leg, while a 50 percent rating is the maximum rating under the code for limitation of extension of the leg. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Diagnostic Code 5262 provides for tibia and fibula impairment. A maximum 40 percent rating is assigned for nonunion of, with loose motion, requiring brace; malunion of with marked knee or ankle disability warrants a 30 percent evaluation; with moderate knee or ankle disability warrants a 20 percent evaluation; and with slight knee or ankle disability warrants a 10 percent evaluation. III. Analysis. III.a. Increased rating, left knee disorder. In this case, the Board finds no basis for a rating in excess of 30 percent for the left knee disorder based upon arthritis with pain and limitation of motion, currently rated under Diagnostic Code 5010-5261. The currently assigned 30 percent rating under this code contemplates limitation of extension of the left leg to 20 degrees. A higher rating would require that extension be limited to 30 degrees. The most recent examination indicated that extension of the left leg was limited to 15 degrees, and flexion was limited to 110 degrees. Accordingly, there is no basis for a higher rating for the left knee disability based on arthritis with pain and limitation of motion. There is no other diagnostic code which could provide a higher rating for the veteran's left knee disability. Were the left knee disability to be evaluated under Code 5260 for limitation of flexion and functional loss due to painful motion, rather than Code 5261, he would not be entitled to a higher evaluation since flexion was limited to 110 degrees at the last examination. Moreover, the maximum ratings under 5258 and 5259 do not provide the veteran with a rating in excess of the current 30 percent rating for his left knee. In regard to functional loss, the Board finds that the veteran's pain on motion due to arthritis has been contemplated by the 30 percent evaluation currently assigned. On examination in October 1997, ROM for the left knee was from 10 degrees extension to 122 degrees of flexion. Examination in November 1998 revealed motion of the knee to be flexion from 0-70 degrees active. Extension was -20 degrees active. Full extension was limited in other words by 20 degrees active. The knee appeared to be stable medial and laterally but anteriorly and posteriorly there appeared to be some laxity with greater than 5mm motion. Examination in May 2002 revealed that the left knee lacked 15 degrees from terminal extension, and had 110 degrees of flexion. There was pain on motion, swelling, enlargement and tenderness of the knee. He was felt to have mild medial collateral ligament laxity with popping and pain noted with valgus stress applied to the knee. Neither examination revealed either recurrent subluxation or lateral instability of mild degree so as to warrant an additional 10 percent rating under Code 5257. Moreover there is no clinical evidence that the medial collateral laxity was related to the service connected arthritis of the knee. As demonstrated in the medical evidence of record, limitation of flexion of the left knee equates to a noncompensable rating. Limitation of extension varied from one examination to another but never equated to more than a 30 percent rating. There is no other diagnostic code which could provide a higher rating for the veteran's left knee disability. Were he to be evaluated under Diagnostic Code 5260 for limitation of flexion and functional loss due to painful motion, rather than Diagnostic Code 5261, he would not be entitled to more than a 10 percent evaluation. In regard to functional loss, the Board finds that the veteran's pain on motion due to arthritis has been contemplated by the 30 percent evaluation currently assigned. In light of the results of examinations in 1997, 1998, and 2002, the Board finds that there is no basis for a rating in excess of 30 percent for left knee disability. Finally, the medical evidence does not show ankylosis of the knees. As such, a rating under Code 5256 is not appropriate in this case. There is no competent evidence of record which indicates that the veteran's service-connected left knee disorder of itself has caused marked interference with employment beyond that which is contemplated under the schedular criteria, or that there has been any necessary inpatient care. Thus, there is no basis for consideration of an extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b)(1). Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). There is nothing in the evidence of record to indicate that the application of the regular schedular standards is impractical in this case. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996). In summary, it is the conclusion of the Board that there is no symptomatology related to the service-connected left knee disability that would warrant a higher rating. The evidence is not so evenly balanced as to give rise to a reasonable doubt. III.b. Secondary service connection. The appellant's primary assertion is that his DJD, left shoulder: degenerative changes, lumbar spine, and cervical spine: and degenerative arthritis, of the ankles were caused by his service connected left knee disability. However, he is not qualified to give credible medical opinion as to diagnosis or cause of disease or injury. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). There is no competent medical opinion that states that the appellant's left shoulder, lumbar spine, cervical spine, or ankle disorders are proximately due to or the result of his service connected left knee disorder. In fact, the VA examiner in May 2002 specifically addressed the veteran's assertion. The examiner noted there was no question that the veteran had marked and severe limitations secondary to his generalized arthritic complaints. However, he opined that; I think that the claim that the multiple areas of arthritis are 'secondary' to the service connected traumatic arthritis of the left knee are somewhat speculative in nature as opposed to rising to the level of reasonable medical certainty or even as likely as not. Current VA records reflect the severity of appellant's generalized arthritis, DDD, and DJD, but do not relate the veteran's left shoulder, lumbar spine, cervical spine, or ankle disorders with his left knee disorder. The Board concludes that there is no competent medical opinion that it is at least as likely as not that the service-connected left knee disorder caused the veteran's left shoulder, lumbar spine, cervical spine, or ankle disorders. Allen v. Brown, 7 Vet.App. 439 (1995). When all of the relevant evidence is assembled, the Board is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against his claims, in which case the claims are denied. See Gilbert v. Derwinski, 1 Vet.App. 49 (1990). In this case, the Board concludes that the preponderance of the evidence is against the claims for service connection for a left shoulder, lumbar spine, cervical spine, or ankle disorder on any basis. IV. Special monthly pension. IV.a. Background. The veteran was found to be permanently and totally disabled for VA pension purposes effective as of January 1996. His nonservice connected disabilities include diabetes mellitus, evaluated as 40 percent disabling; and hypertension, evaluated as 10 percent disabling. The combined rating was 50 percent. Subsequently he filed a claim in August 2001 for entitlement to special monthly compensation based on the need for regular aid and attendance or being housebound. In addition he also claimed entitlement to special monthly compensation based on his service connected left knee disorder rated at that time at 10 percent disabling. By rating action in October 2001 entitlement to a special monthly compensation or pension on both bases claimed was denied. In making that determination the RO noted the veteran was not bedridden, and not blind. He did not have loss of bladder control or anal sphincter control. He dressed, bathed, used bathroom facilities, and fed himself more than 50 percent of the time, and could protect himself from the hazards of life. There was no medical evidence submitted to show the veteran was housebound or in need of aid and attendance benefits. In a December 2001 VA aid and attendance/housebound examination, the examiner noted a history of insulin dependent diabetes, severe arthritis, spinal stenosis, and hypertension. The veteran also had a work-up for heme- positive stools which revealed hemorrhoids and colon polyps. He also had a history of erectile dysfunction and gout. There was a note that he was having a ramp installed at his home because he could no longer go up steps. A neurosurgery clinic note indicated signs of spinal claudication. The veteran lived at home with his wife, son and his family. He reported being hospitalized 6 months prior for high blood sugar. He denied vision complaints. He stayed home most of the time. He reported several musculoskeletal problems. He could walk a few steps then he has to stop secondary to pain. His wife and son did the cooking, shopping, and laundry. He could feed himself, dress, and use the restroom by himself. He needed assistance bathing, and getting out of a chair. He denied incontinence. He reportedly stayed home most of the time because of pain and poor ambulation. He left his house mostly to see doctors. He watched TV and read most of the time. He currently did not have a cane or a walker. He had a knee brace which he does not wear all the time. The examiner noted the veteran was not in any apparent distress. He was in a fair state of nutrition. He presented in a hospital wheelchair, but was able to walk unassisted for a few yards. However his gait was slow with a slight limp. He complained of back pain, as well as generalized arthritis. The examiner noted in the report that the veteran was ambulatory, and left the house for medical appointments and social events. He was not visually impaired and had no assistive ambulation device at the time of examination. He apparently had a car with which he was able to get around. In September 2002, the veteran submitted a written request to cancel his claim of entitlement to a special monthly compensation. IV.b. Criteria and analysis. Since 1996, the veteran has had a permanent and total disability rating for VA pension purposes. The veteran now seeks a higher level of pension due to his professed need for the regular aid and attendance of another person or due to his claim that he is housebound. The regulations provide that where an otherwise eligible veteran is in need of regular aid and attendance or is permanently housebound, an increased rate of pension is payable. 38 U.S.C.A. § 1521(d). For pension purposes, a person shall be considered to be in need of regular aid and attendance if such person is (1) a patient in a nursing home or, (2) helpless or blind, or so nearly so helpless or blind as to need or require the regular aid and attendance of another person. 38 U.S.C.A. § 1502(b). The requirement of being permanently housebound will be considered to have been met when the veteran is substantially confined to such veteran's house or immediate premises due to a disability or disabilities which it is reasonably certain will remain throughout such veteran's lifetime. 38 U.S.C.A. § 1502(c). The need for aid and attendance means helplessness or being so nearly helpless as to require the regular aid and attendance of another person. 38 C.F.R. § 3.351(b). The veteran will be considered in need of regular aid and attendance if he or she: (1) Is blind or so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; or (2) is a patient in a nursing home because of mental or physical incapacity; or (3) establishes a factual need for aid and attendance under the criteria set forth in 38 C.F.R. § 3.352(a). 38 C.F.R. § 3.351(c). The following will be accorded consideration in determining the need for regular aid and attendance: Inability of claimant to dress or undress himself (herself), or to keep himself (herself) ordinarily clean and presentable, frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back etc.); inability of claimant to feed himself (herself) through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. "Bedridden" will be a proper basis for the determination. For the purpose of this paragraph "bedridden" will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. It is not required that all of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions which the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the veteran is so helpless, as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. 38 C.F.R. § 3.352(a). The rate of pension payable to a veteran who is entitled to pension who is not in need of regular aid and attendance shall be as prescribed in 38 U.S.C.A. § 1521(e), if in addition to having a single permanent disability rated 100 percent disabling under the Schedule for Rating Disabilities (not including ratings based upon unemployability under § 4.17 of this chapter) the veteran: (1) Has additional disability or disabilities independently ratable at 60 percent or more, separate and distinct from the permanent disability rated as 100 percent disabling and involving different anatomical segments or bodily systems, or (2) is "permanently housebound" by reason of disability or disabilities. This requirement is met when the veteran is substantially confined to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 C.F.R. § 3.351(d). As to the veteran's entitlement to aid and attendance benefits, it is noted that in the report of a VA examination in May 2002, the medical examiner noted that the veteran was markedly symptomatic with multiple arthritic complaints. He described pain in the neck, shoulder, back, ankles, and left knee. He could not bend, or lift and weight bearing was painful. He was issued a motorized wheelchair and was having a ramp installed in his house. The examiner noted the veteran had severe posttraumatic arthritis, degenerative changes of the cervical and lumbar spines, etc. There was no question that he had marked and severe limitation secondary to his generalized arthritic complaints. In pertinent part, the VA evaluation in May 2002 reveals that the veteran requires the regular aid and assistance of another because of his severe generalized arthritis requires assistance more than fifty percent of the time for him to perform activities of daily living. However, he is not housebound as he is able to get out to family functions and medical appointments. That being the case, it is determined that the veteran is entitled to special monthly pension due to the need for the aid and attendance of another but is not permanently housebound. ORDER Entitlement to a rating in excess of 30 percent for a left knee disability based upon arthritis, pain and limitation of motion is denied. Entitlement to service connection for degenerative joint disease (DJD), left shoulder, with probable rotator cuff tear as secondary to the service connected left knee disability is denied. Entitlement to service connection for degenerative changes, lumbar spine, to include as secondary to the service connected left knee disability is denied. Entitlement to service connection for degenerative changes, cervical spine, to include as secondary to the service connected left knee disability is denied. Entitlement to service connection for degenerative arthritis, right ankle, to include as secondary to the service connected left knee disability is denied. Entitlement to service connection for degenerative arthritis, left ankle, to include as secondary to the service connected left knee disability is denied. Special monthly pension by reason of the need for aid and attendance of another is granted, subject to those provisions governing the payment of monetary benefits. Special monthly pension by reason of being housebound is denied. ____________________________________________ M. W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.