Citation Nr: 0503704 Decision Date: 02/11/05 Archive Date: 02/22/05 DOCKET NO. 03-07 442 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability. 3. Entitlement to service connection for a heart condition. 4. Entitlement to service connection for a left arm disorder, claimed as pain. 5. Evaluation of hemorrhoids, currently rated as zero percent disabling. 6. Evaluation of shin splints of the right leg, currently rated as zero percent disabling. 7. Evaluation of shin splints of the left leg, currently rated as zero percent disabling. 8. Evaluation of bronchial asthma, currently rated as zero percent disabling. 9. Evaluation of benign ovarian cyst, currently rated as zero percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD David T. Cherry, Counsel INTRODUCTION The veteran served on active duty from April 1997 to April 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), located in Reno, Nevada. The veteran presented oral testimony at a hearing held in Las Vegas, Nevada, in March 2004 before the undersigned Veterans Law Judge. At the March 2004 hearing, the veteran indicated that she was withdrawing the claim of entitlement to service connection for a cervical spine disorder. Therefore, the issues are listed on the title page. The issues of evaluation for benign ovarian cyst is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. In a November 2001 claim, the veteran raised the issue of service connection for a scar on the left elbow. In the October 2002 rating decision, the RO granted service connection for a right knee scar. While the rating decision mentions a scar on the left elbow, the issue of service connection for that scar was not specifically adjudicated. This matter is referred to the RO. FINDINGS OF FACT 1. There is no competent medical evidence that the veteran currently has a right knee disability. 2. There is no competent medical evidence that the veteran currently has a left knee disability. 3. The evidence shows that the intermittent sinus tachycardia is not due to a cardiovascular disease or in- service injury and that the veteran does not have another cardiovascular disease. 4. There is no competent medical evidence that the veteran has a current left arm disability, claimed as pain. 5. The evidence does not show that the veteran has hemorrhoids that are large or thrombotic, are irreducible, have excessive redundant tissue, or evidence frequent recurrences. 6. The right shin splint is manifested by mild-to-moderate tenderness over the medial face of the tibia and slight functional impairment with no X-ray finding of abnormality. 7. The left shin splint is manifested by mild-to-moderate tenderness over the medial face of the tibia and slight functional impairment with no X-ray finding of abnormality. 8. The bronchial asthma is manifested by Forced Expiratory Volume in one second (FEV-1) at 95 percent of predicted value and Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 93 percent and by intermittent inhalational or oral bronchodilator therapy. CONCLUSIONS OF LAW 1. A right knee disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2004). 2. A left knee disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2004). 3. The sinus tachycardia is not due to a disease or injury that was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2004). 4. A heart condition was not incurred in or aggravated by service and may not be presumed to have been incurred during service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2004). 5. A left arm disability, claimed as pain, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2004). 6. The criteria for an evaluation in excess of zero percent for hemorrhoids have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2004). 7. The right shin splint is 10 percent disabling. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2004). 8. The left shin splint is 10 percent disabling. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2004). 9. Bronchial asthma is 10 percent disabling. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.114, Diagnostic Code 6602 (2004). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VCAA Initially, the Board is satisfied that all relevant facts regarding the issue decided below have been properly developed and no further assistance to the veteran is required in order to comply with the duty to notify or assist. See 38 U.S.C.A. §§ 5103, 5103A, 5107(a) (West 2002). As discussed below, the development conducted by VA in this case fully meets the requirements of the old provisions of 38 U.S.C.A. § 5107(a) (West 1991) and the new provisions of 38 U.S.C.A. §§ 5103, 5103A (West 2002). See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). This law redefines the obligations of VA with respect to the duty to assist and includes an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The final rule implementing the VCAA is codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2004). This change in the law is applicable to all claims filed on or after the date of enactment of the VCAA (November 9, 2000), and to claims filed before the date of enactment but not yet final as of that date. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002). First, VA has a duty to provide an appropriate claim form, instructions for completing it, and notice of information necessary to complete the claim if it is incomplete. 38 U.S.C.A. § 5102; 38 C.F.R. § 3.159(b)(2). In this case, there is no issue as to providing an appropriate application form or completeness of the application. Second, VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In this case, the veteran challenged the evaluation in her notice of disagreement to the October 2002 rating decision granting service connection for hemorrhoids, shin splints of the right leg, shin splints of the left leg, and bronchial asthma. If, in response to notice of its decision on a claim for which VA has already given the section 5103(a) notice, VA received a notice of disagreement that raises a new issue, section 7105(d) requires VA to take proper action and issue a statement of the case if the disagreement is not resolved, but section 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate the newly raised issue. VAOPGCPREC 8-2003 (Dec. 22, 2003). The Board finds that the requirements of section 7105(d) have been met, as a statement of the case pertaining to the issues of the evaluations was sent to the veteran after the receipt of her notice of disagreement. As for providing section 5103(a) notice, only after the October 2002 rating action was promulgated did the agency of original jurisdiction (AOJ), in January 2004, provide explicit notice to the veteran regarding what information and evidence is needed to substantiate the claims, as well as what information and evidence must be submitted by the veteran, and what information and evidence will be obtained by VA. The AOJ provided the veteran an October 2002 rating decision and a statement of the case (SOC) in February 2003 that included a summary of the evidence, the applicable law and regulations and a discussion of the facts of the case. These gave notice as to the evidence generally needed to substantiate her claims. The AOJ wrote to the veteran in January 2004 regarding the notification of the passage of the VCAA and the obligations of VA with respect to the duty to assist and duty to notify regarding the information and evidence necessary to substantiate her claims. Specifically, the veteran was notified that VA has a duty to assist her in obtaining evidence necessary to substantiate her claim. The veteran was notified that she should identify medical treatment and that VA would request identified medical evidence. Here, the Board finds that any defect with respect to the timing of the VCAA notice requirement is harmless error. While the notice provided to the veteran in January 2004 was not given prior to the first AOJ adjudication of the claim, the content of the notice fully complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). The veteran has been provided with every opportunity to submit evidence and argument in support of her claims, and to respond to VA notices. Proper process has been provided. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Third, VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. §§ 5107(a), 5103A ; 38 C.F.R. § 3.159(c). Records pertinent to the current claim in the possession of the Federal government - past treatment records with the military and VA medical records - have been obtained. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(2), (3). In addition, the veteran was afforded VA examinations. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The veteran has not identified any recent treatment by VA or any other source. In addition, the October 2002 rating decision and the February 2003 SOC informed the veteran of the evidence in the possession of VA. As it appears that VA has obtained all pertinent evidence, there is no duty to notify the veteran of an inability to obtain identified records. See 38 U.S.C.A. § 5103A(b)(2), (3); 38 C.F.R. § 3.159(e). Additionally, in the January 2004 VCAA letter, the RO told the veteran that she could submit any additional evidence that supported her claims. In a June 2004 letter, the RO informed that the veteran should submit any additional evidence concerning her appeal to the Board. Put simply, the RO in essence told the veteran to submit any evidence in her possession that pertains to her claims. Therefore, any lack of an explicit request to submit any evidence in the veteran's possession is a harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). By the June 2004 letter, VA informed the veteran that her case was being forwarded to the Board and, in effect, that VA would not undertake any further development in his claim. Based on the above analysis, the Board finds that VA has fulfilled its duty to assist the veteran in the development of the claims decided below. In light of the above, the Board determines that no reasonable possibility exists that further assistance would aid in the substantiation of the veteran's claims. 38 U.S.C.A. § 5103A. In addition, as the veteran has been provided with the opportunity to present evidence and arguments on her behalf and availed herself of those opportunities, appellate review is appropriate at this time. See Bernard v. Brown, 4 Vet. App. 384, 393 (1993). II. Factual Background Service medical records reflect that in March 1997 the veteran complained of left knee pain. Following a physical examination, the assessment was to rule out a medial tibial plateau stress fracture. In April 1997 the veteran underwent bone scan, which revealed bilateral focal increased activity with the medial tibial plateaus of both knees and likely represented stress fractures. X-rays of the left tibia and fibula taken in April 1997 was normal. A physical examination on May 5, 1997, revealed no muscle atrophy and a full active range of motion in both knees. The assessment was bilateral medial tibial plateau stress fracture. A physical examination on May 19, 1997, revealed that mild quadriceps atrophy was present bilaterally and that range of motion in both knees from zero degrees to 135 degrees. A physical examination on May 27, 1997, revealed mild quadriceps atrophy bilaterally and full range of motion in both knees. In June 1997 she had no muscle atrophy and had full range of motion in both knees. Also, in June 1997 the impression had been changed to bilateral shin splints/tibial periostitis. In July 1997, the impression was bilateral tibial periostitis. Service medical records show that in August 1998, the veteran's pulse was reported as being either 100 or 72 beats per minute. In September 1999, the veteran's pulse was 84 beats per minute. A September 1999 electrocardiogram (EKG) revealed a normal sinus rhythm and was considered to be normal. In May 2000 the veteran's pulse was 92 beats per minute and the assessments included a family history of cardiovascular disease. In August 2000, the veteran complained of dizziness after a one-mile run. Her pulse was 105 beats per minute, and it was noted that she had a prior medical history of tachycardia as a baseline. The assessment was post-exercise vagal reaction. A November 2000 Holter report revealed a normal sinus rhythm and no dysrhythmia. In January 2001, the veteran's pulse was 92 beats per minute. At the March 2001 separation examination, the veteran denied having or having had a "trick" or locked knee, palpitation, or pounding heart. She reported that she had had heart trouble. In that regard, the examining physician noted that the veteran had an exercise-induced bronchospasm per pulmonary function tests on November 20, 2002, and a normal Holter monitor on November 20, 2002. The physical examination revealed an external hemorrhoid that had mild erythema and was reducible in the 6 o'clock position. The heart was normal. The upper and lower extremities were normal. Her pulse was 98 beats per minute when sitting, 82 beats per minute in a recumbent position, and 107 beats per minute three minutes after standing. VA medical records reflect that a physical examination in July 2001 revealed that the heart had a regular rhythm and that no murmur, S3, or S4 was present. The veteran was tachycardic. The diagnoses included tachycardia. A September 2001 EKG revealed a normal sinus rhythm and was considered normal. A May 2002 VA gynecological examination revealed that the veteran's heart had a regular sinus rhythm without murmurs appreciated. The veteran had a cardiovascular examination in May 2002. She reported that she had had a fast heart rate for the past two to three years. Physical examination revealed a heart rate of 84 beats per minute on two separate occasions. No murmurs or gallop sounds were audible. No precordial pulsations were palpable. The veteran underwent treadmill stress testing in June 2002. She was able to be tested for over 10 minutes in duration, and achieved 13 metabolic equivalents (METS). The study was limited by exhaustion and fatigue. She had a hypertensive response to exercise, and no arrhythmia was noted. The veteran's baseline EKG at the time of the treadmill testing was normal. In June 2002 the veteran also underwent an echocardiogram, which showed no abnormality. The heart chambers had normal dimensions. There was normal systolic function of the left ventricle. The valves appeared normal. There was a trivial tricuspid regurgitation, which was physiologic in nature. The veteran was placed on an event monitor to try to capture whether she was having any rhythm disturbance. She wore this device for approximately two weeks. She complained intermittently of shortness of breath, dizziness, and chest tightness. No rhythm disturbance other than intermittent tachycardia with heart rates up to 170 beats per minute was noted. There were no S-T segment changes. The examiner indicated that there was no documented arrhythmia even with the veteran being symptomatic. The examiner noted that the veteran does develop sinus tachycardia intermittently, which may be related at least in part to poor physical conditioning. The examiner reported that no other cardiovascular abnormality was uncovered. The examiner indicated that the veteran had excellent exercise tolerance and was able to achieve 15 METS on the treadmill. The examiner stated that the chest pain and arm pain, which she had complained about, would not be related to any cardiovascular problem. The veteran had a VA gastroenterological examination in May 2002. She reported a past history of external hemorrhoids. She denied any present rectal bleeding or hematochezia. She also denied constipation or loose bowel movements, loss of sphincter control, or fecal leakage. A physical examination of the cardiovascular system revealed that the heart sounds were normal and that there were no murmurs, rubs, or gallops. There was leg edema and no carotid bruit. A colonoscopy revealed small non-bleeding internal hemorrhoids. The impression was internal hemorrhoids on flexible colonoscopy that were totally asymptomatic. The veteran underwent a VA bones examination in May 2002. She reported that she had episodes of pain over the anterior shin of both legs, which occurred two to three times a week and lasted for approximately four hours per episode. She denied any redness or heat. She indicated that she had episodes of anterior medial knee pain once a week, which lasted for two hours, but she denied any swelling or loss of motion in the knees. In the ankles, she had no complaints of swelling, pain, or loss of motion. She denied any instability, locking, giving way of the legs, or weakness. She reported that she took 250 milligrams of Naprosyn four times a day without complications. She indicated that her bilateral tibial condition was stable without flare ups and that she had no restrictions regarding her work activities or activities of daily living. Physical examination revealed that the veteran was able to walk on her heels and toes, and performed a 100 percent normal squatting maneuver without difficulty. There was no objective abnormalities regarding her tibias. There was no deformity, angulation, or shortening. There was no malunion, nonunion, or false joints. There was mild tenderness with direct palpation on the subcutaneous borders of both tibias. There was no swelling, redness, weakness, or drainage. There was no painful motion involving the knees or ankles. The veteran had a normal gait with normal foot callosities and shoe wear patterns. There was no ankylosis. Both knees had an active normal range of motion from to zero to 140 degrees without pain or swelling. Both ankles had a 100 percent normal active range of motion against moderate resistance with dorsiflexion to 20 degrees and plantar flexion to 45 degrees without pain, swelling, or instability. The leg lengths were equal. There were no constitutional signs of bone disease, and there was no weight loss, fever, or debility. X-rays of the both tibias were normal. The diagnosis was mild anterior tibial shin splint that was intermittent in nature and was without neurologic or mechanical deficit. The veteran also underwent a VA joints examination in May 2002. She reported that she had momentary left arm pain and numbness, which occurred when she sneezed. She stated that she developed bilateral anterior knee pain in service at the same time she had shin splints. Her current complaints were episodes of aching pain involving the medial aspect of her knees that occur approximately one time per week and last for two hours. She denied any swelling, locking, clicking, instability, limited motion, or giving way of her knees. She reported that occasionally, her knees felt weak. Physical examination revealed that she easily performed a squatting maneuver. The left upper extremity had a normal appearance. The left shoulder had a 100 percent, normal, pain-free active range of motion with forward flexion to 180 degrees, abduction to 180 degrees, internal rotation to 90 degrees, and external rotation to 90 degrees. The left elbow had a 100 percent, normal, pain-free active range of motion with flexion to 145 degrees, supination to 85 degrees, and pronation to 80 degrees. There was no tenderness or swelling about the elbow. There was 100 percent, normal, pain-free active range of motion of the left wrist with dorsiflexion to 70 degrees, palmar flexion to 80 degrees, radial deviation to 20 degrees, and ulnar deviation to 45 degrees. She had a normal grip strength and easily made a fist with the left hand. The knees had a normal appearance. The knees had 100 percent, normal, pain-free range of motion with flexion from zero to 140 degrees. There was no tenderness or swelling in the knees. Ligaments were intact to varus and valgus stresses. The drawer signs were normal. The McMurray's tests and Lachman's tests were normal. X-rays of the both knees were normal. The diagnoses were intermittent episodes of bilateral knee pain without neurologic or mechanical deficit and no clinical findings of thoracic outlet syndrome on examination. The veteran underwent a VA respiratory examination in June 2002. She stated that the frequency of asthma attacks depended on how often she exerted herself and that an attack lasted approximately 30 to 45 minutes. She reported that she used Ventolin on as needed basis. She denied any periods of incapacitation. Physical examination revealed no presence of cor pulmonale, right ventricular hypertension, or pulmonary hypertension. There was no evidence of restrictive disease. Pulmonary function tests revealed that Forced Expiratory Volume in one second (FEV-1) was 95 percent of predicted value and that Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) was 93 percent. The report of chest X-rays reflects that there was some bronchial and peribronchial thickening suggesting bronchitis of either an acute or chronic nature, and that the heart was normal. The radiologist's impression was bronchitis. The VA examiner made the following diagnoses: no evidence of obstructive or restrictive ventilatory defect; normal diffusing capacity; no clinical evidence of acute or chronic bronchitis; and bronchial asthma by exertion and by history. VA medical records reflect that at a January 2003 and January 2004 annual gynecological examinations, the veteran's heart had a normal sinus rhythm without a murmur. The veteran was afforded a VA bones examination in February 2004. She reported that she continued to have consistent aching pain in her lower legs. She said the pain was aggravated by long standing or walking, which resulted in episodes of swelling in the lower thirds of both tibias, and which she described as a three or four on a scale of one to ten. She noted that she had full pain-free unrestricted motion of both knees and ankles with normal sensation involving both feet. She indicated that she used Naproxen three or four times a week. She stated that flare ups occur once or twice a week and last for as long as one day, with the pain being a seven or eight on a scale of one to ten. She noted that during a flare up, she was able to do all activities involving daily living and does not alter her normal daily activities, other than to avoid standing or walking for more than 20 minutes. She indicated that she was able to do all of the activities of her job, a sales associate, and of daily living. Physical examination revealed the veteran did not require a cane or assistive device to ambulate. She easily walked on her heels and toes, but complained of pain in the lower thirds of both tibias while walking on her toes. She performed a 100 percent normal squatting maneuver without difficulty. There were no objective abnormalities involving the lower legs other than direct tenderness over the medial face of both tibias, which involved the distal thirds of both tibias but not the ankles or knees. There was no deformity angulation or shortening of the legs. There was no malunion, nonunion, or fracture involving the tibias. There was moderate direct tenderness over the medial face of both tibias absent the ankle joints. There was no drainage, swelling, redness, or heat. She had full, pain-free motion of both knees and ankles, and there was no obvious weakness involving the lower legs. She had a normal gait with normal shoe wear patterns and normal colostomies on her feet. There was no ankylosis involving the joints in the lower extremities. Both knees had a normal appearance with 100 percent normal active range of motion against strong resistance and without pain. Both knees flexed from zero to "50" degrees without pain. There was no swelling of the knees, and the ligaments were intact to varus and valgus stress. There was a normal Drawer sign, and McMurray's and Lachman's tests were negative. Both ankles had 100 percent normal, pain-free range of motion. Dorsiflexion was to 20 degrees without pain, and lateral flexion was to 45 degrees without pain. There was no swelling or tenderness about the ankles. The veteran had normal feet with normal alignment and no swelling or tenderness. The examiner noted that during the course of a flare-up, the veteran had no limited motion or pain involving the knees or ankles and that during such an episode, it was expected that the veteran reduce her walking by 20 percent. The leg lengths were equal. She had no weight loss, fevers, or debility. X-rays of the tibias and the ankles were normal. The diagnosis was bilateral chronic shin splints involving both tibias without neurologic or mechanical deficits. The veteran had a VA gastroenterological examination in February 2004. She denied any rectal bleeding, hematochezia, or change in bowel habits. A physical examination of the cardiovascular system revealed that the heart sounds were normal and that there were no murmurs, rubs, or gallops. There was leg edema and no carotid bruit. She declined a colonoscopy. The impression was a past history of rectal bleeding with current non-bleeding internal and external hemorrhoids that were totally asymptomatic. The veteran underwent VA pulmonary function test in February 2004. FEV-1 was 112 percent of predicted value and FEV-1/FVC was 117 percent. VA chest X-rays taken in February 2004 revealed no active disease. The veteran underwent a VA respiratory examination in March 2004. She reported that she continued to suffer from paroxysms of shortness of breath associated with chest tightness, wheezing, and cough suggestive of asthma, which were mostly precipitated by exercise. She indicated that if she exercised without taking Ventolin, she had an asthma attack and that she had asthma even at times of rest. She noted that the precipitating factors were high winds and exposure to cigarette smoke. She denied any history of chronic cough, hemoptysis, fever, chills, or chest pains. The physical examination of the heart revealed that S1 and S2 had a regular rate and rhythm. There were no rubs, clicks, or murmurs. Following the physical examination, the assessments were exercise-induced asthma and asthma. The examiner noted that she continued to suffer from asthmatic problems and was dependent on a Ventolin inhaler not only to prevent attacks but also to treat her attacks. At the March 2004 hearing, the veteran testified that her bilateral knee symptomatology began at the same time in service that the shin splints began. She stated that no medical professional has diagnosed disorders causing her cardiac symptomatology and left arm symptomatology. The veteran testified that the hemorrhoidal symptomatology was intermittent and that there was sometimes bleeding. She also indicated that she had difficulty sitting during a hemorrhoidal flare up. She described the pain from her shin splints as being a 9 on a scale of 1 to 10. She stated that she could not do any exercising except for swimming. She noted that her shin splints did not interfere with her current job because she was able to sit, but that she had quit a management position because that position required her to walk around. She also reported that she only used her Ventolin inhaler during asthmatic attacks, which only occurred three to four times a month. At an April 2004 VA gynecological examination, the veteran's heart had a normal sinus rhythm. III. Service Connection Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b) (2004). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. Service connection may be also 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). Service connection may also be granted for a cardiovascular disease when it is manifested to a compensable degree within one year following discharge from active service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection connotes many factors, but basically, it means that the facts, as shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service. A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease in service. See Pond v. West, 12 Vet. App. 341 (1999); Watson v. Brown, 4 Vet. App. 309, 314 (1993). In claims for VA benefits, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990) (holding that a claimant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail). IV. Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (2004). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2004). Hemorrhoids with persistent bleeding and with secondary anemia, or with fissures warrant a 20 percent evaluation. Where hemorrhoids are large or thrombotic, are irreducible, have excessive redundant tissue, and evidence frequent recurrences, a 10 percent evaluation is required. Mild or moderate hemorrhoids warrant assignment of a zero percent evaluation. 38 C.F.R. § 4.114, Diagnostic Code 7336 (2004). The rating schedule provides that when an unlisted disability is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2004). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45 (2003). The United States Court of Appeals for Veterans Claims (Court) has held that the RO must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) did not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The Board noted that the guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. A 40 percent disability rating is warranted for nonunion of the tibia and fibula, with loose motion and a brace. For a malunion of the tibia and fibula, 30, 20, and 10 percent disability ratings are warranted for marked, moderate, and slight knee or ankle disabilities, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2004). Standard motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2004). Limitation of leg flexion is rated 0 percent when limited to 60 degrees, 10 percent when limited to 45 degrees, 20 percent when limited to 30 degrees, and 30 percent when limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2004). Limitation of leg extension is rated 0 percent when limited to 5 degrees, 10 percent when limited to 10 degrees, 20 percent when limited to 15 degrees, 30 percent when limited to 20 degrees, and 40 percent when limited to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2004). The standard range of motion of the ankle is from 20 degrees of dorsiflexion to 45 degrees of plantar flexion. 38 C.F.R. § 4.71, Plate II (2004). A 20 percent evaluation is warranted for marked limitation of motion, and a 10 percent disability rating requires a moderate limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2004). A 10 percent rating is warranted when there is evidence of bronchial asthma with FEV-1 of 71 to 80 percent of the predicted value; or FEV- 1/FVC of 71 to 80 percent of the predicted value; or the need for intermittent inhalational or oral bronchodilator therapy. A 30 percent rating requires FEV-1 of 56 to 70 percent of the predicted value; or FEV- 1/FVC of 56 to 70 percent of the predicted value; or the need for daily inhalational or oral bronchodilator therapy or inhalational anti-inflammatory medication. A 60 percent rating is warranted for bronchial asthma with FEV-1 of 40 to 55 percent of the predicted value; or FEV-1/FVC of 40 to 55 percent of the predicted value; or at least monthly visits to a physician for required care of exacerbations; or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 100 percent rating for bronchial asthma is warranted for FEV-1 of less than 40 percent of the predicted value; or FEV-1/FVC less than 40 percent of the predicted value; or more than one attack per week, with episodes of respiratory failure; or when daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications is required. 38 C.F.R. § 4.97, Diagnostic Code 6602 (2004). V. Analysis A. Service Connection 1. Right and Left Knee Disabilities Although the veteran had complaints of left knee pain in service in March 1997, a left knee disorder, as opposed to a disorder involving the medial tibial plateau, was not diagnosed. On the March 2001 separation examination, a knee disorder was not diagnosed. At the May 2002 VA bones examination, both knees had a full range of motion with no pain or swelling during range of motion testing. A knee disorder was not diagnosed at that examination. At the May 2002 VA joints examination, both knees again had a full range of motion with no pain during range of motion testing. There was no tenderness or swelling in the knees. Ligaments were intact to varus and valgus stresses. The drawer signs were normal. The McMurray's tests and Lachman's tests were normal. X-rays of the both knees were normal. The relevant diagnosis was intermittent episodes of bilateral knee pain without neurologic or mechanical deficit. At the February 2004 VA bones examination, both knees had 100 percent, normal active range of motion against strong resistance and without pain on testing. There was no swelling of the knees, and the ligaments were intact to varus and valgus stress. There was a normal Drawer sign, and McMurray's and Lachman's tests were negative. A knee disorder was not diagnosed. Also, no other medical professional has diagnosed a knee disorder. Although the diagnosis of the May 2002 VA joints examiner was intermittent episodes of bilateral knee pain without neurologic or mechanical deficit, at this time there is no competent evidence that the veteran has a disease or injury to account for her complaints. At best, there is a complaint of pain without underlying pathology. In the absence of in- service disease or injury, service connection may not be granted. Pain cannot be compensable in the absence of an in- service disease or injury to which the pain can be connected by medical evidence. Such a "pain alone" claim must fail when there is no sufficient showing that pain derives from an in-service disease or injury. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). The preponderance of the evidence is against the claims, and there is no doubt to be resolved. 38 U.S.C.A. § 5107; Gilbert, 1 Vet. App. at 55. Service connection for a right knee disability and a left knee disability is denied. 2. Heart Condition Service medical records do not show a diagnosis of a cardiovascular disorder. Instead, they reflect that the veteran had a history of tachycardia and that high pulse rates were noted. Also, the September 1999 EKG was normal and in August 2000 the assessment was post-exercise vagal reaction. A cardiovascular disorder was not diagnosed on the March 2001 separation examination. Tachycardia was diagnosed in July 2001 and, more specifically, the May 2002 VA cardiovascular examination reflects that the veteran has intermittent sinus tachycardia. However, the VA examiner indicated that the sinus tachycardia may be related at least in part to poor physical conditioning. The examiner reported that no other cardiovascular abnormality was uncovered, and no other medical professional has diagnosed another cardiovascular disorder. In other words, the intermittent sinus tachycardia has not be attributed to a cardiovascular disease or an injury that was incurred in or aggravated by active service. See Sanchez-Benitez, 259 F.3d at 1361; 38 C.F.R. §§ 3.304, 3.307, 3.309. Also, there is no diagnosis of a cardiovascular disease. The preponderance of the evidence is against the claim, and there is no doubt to be resolved. 38 U.S.C.A. § 5107; Gilbert, 1 Vet. App. at 55. Service connection for a heart condition is denied. 3. Left Arm Disability Service medical records do not reflect complaints, findings, or treatment of a left arm disability. On the May 2001 separation examination, the upper extremities were normal. The May 2002 VA cardiovascular examiner did not diagnosis a left arm disability and indicated that the complaints of chest and left arm pain would not related to any cardiovascular problem. The May 2002 VA joints examiner also did not diagnosis a left arm disability and indicated that there were no clinical findings of thoracic outlet syndrome on the physical examination. No other medical professional has diagnosed a left arm disability. While the veteran complains of left arm pain, there is no competent evidence that the veteran has a disease or injury to account for her complaints. Pain alone is not a disability. See Sanchez- Benitez, 259 F.3d at 1361. In short, the evidence shows that there is no competent medical evidence that the veteran has a left arm disability. The preponderance of the evidence is against the claim, and there is no doubt to be resolved. 38 U.S.C.A. § 5107; Gilbert, 1 Vet. App. at 55. Service connection for a left arm disability, claimed as pain, is denied. B. Increased Ratings 1. Hemorrhoids In Fenderson v. West, 12 Vet. App 119 (1999), the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case (such as this one) in which the veteran expresses dissatisfaction with the assignment of initial disability evaluation where the disability in question has just been recognized as service-connected. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim - a practice known as "staged rating." In this case, the condition has not changed and an uniform evaluation, rather than a "staged rating," is warranted. On the March 2001 separation examination, the only hemorrhoid found was a reducible external hemorrhoid. At the May 2002 VA examination, the veteran denied any present rectal bleeding or hematochezia. A colonoscopy revealed small, non- bleeding internal hemorrhoids. The impression was totally asymptomatic internal hemorrhoids. At the February 2002 VA examination, she again denied any rectal bleeding or hematochezia. The impression was a past history of rectal bleeding with current non-bleeding internal and external hemorrhoids that were totally asymptomatic. At the hearing, the veteran testified that she sometimes had rectal bleeding and had difficulty sitting during the flare ups, which were intermittent. In short, the evidence does not show that the veteran has hemorrhoids that are large or thrombotic, are irreducible, have excessive redundant tissue, or evidence frequent recurrences. Also, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign a higher rating. The preponderance of the evidence is against the claim, and there is no doubt to be resolved. 38 U.S.C.A. § 5107; Gilbert, 1 Vet. App. at 55. 2. Right and Left Shin Splints In this case, the conditions have not changed and uniform evaluations, rather than a "staged ratings," are warranted. Fenderson, 12 Vet. App. at 126. At the May 2002 VA bones examination, there was mild tenderness with direct palpation on the subcutaneous borders of both tibias. The diagnosis was mild anterior tibial shin splint that was intermittent in nature and was without neurologic or mechanical deficit. At the February 2004 VA bones examination, there was direct moderate tenderness over the medial face of both tibias at the distal thirds. The February 1994 VA bones examiner noted that the veteran reduced her walking by 20 percent during a flare up of shin splints. Such findings reflect a slight impairment of both tibias. Although the initial diagnosis in service was bilateral stress fractures, there is no evidence of a malunion or a nonunion of either the right tibia and fibula or the left tibia and fibula. X-rays of the tibias taken in May 2002 were normal. X-rays of the tibias taken in February 2004 were normal, and the February 2004 VA examiner specifically noted that there was no malunion, nonunion, or fracture involving the tibias. Furthermore, there is no evidence of a moderate knee or ankle disability in either lower extremity or of a moderate impairment of either tibia. The three VA examinations reflect that there was no limitation of motion in either knee or either ankle and no pain on motion in any of those joints. In fact, the February 2004 VA examiner noted that the veteran had no limited motion or pain involving the knees or ankles during a flare up of shin splints. Such findings reflect no functional impairment of the knees or ankles from the bilateral shin splints, and therefore 38 C.F.R. §§ 4.40 and 4.45 are not applicable. In short, ratings in excess of 10 percent under Diagnostic Code 5262 or the diagnostic codes for limitation of motion of the knees and ankles (Diagnostic Codes 5260, 5261, and 5271) are not warranted for shin splints of either lower extremity. Also, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign higher ratings. 3. Bronchial Asthma In this case, the condition has not changed and an uniform evaluation, rather than a "staged rating," is warranted. Fenderson, 12 Vet. App. at 126. The June 2002 VA pulmonary function tests revealed that FEV-1 was 95 percent of predicted value and FEV-1/FVC was 93 percent. February 2004 VA pulmonary function tests revealed that FEV-1 was 112 percent of predicted value and that FEV- 1/FVC was 117 percent. These results do not warrant a 10 percent rating. However, the evidence shows that the veteran uses intermittent inhalational therapy. She reported at the June 2002 VA examination that she used Ventolin on as needed basis. Also, the March 2004 VA examiner noted that the veteran was dependent on a Ventolin inhaler for prevention and treatment of attacks. At the hearing, the veteran testified that she only used her Ventolin inhaler three to four times a month, which was the frequency of her asthmatic attacks. Accordingly, a 10 percent disability rating is warranted. However, there is no evidence that she uses daily inhalational or oral bronchodilator therapy or that inhalational anti-inflammatory medication is required. Therefore, a rating in excess of 10 percent is not warranted. Also, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign higher rating. The Board notes that the impression of the radiologist reading the June 2002 chest X-rays was bronchitis, either of a chronic or acute nature. However, the June 2002 VA examiner diagnosed no clinical evidence of acute or chronic bronchitis and the March 2004 VA examiner did not diagnosis chronic bronchitis. Therefore, Diagnostic Code 6800 (chronic bronchitis) is not applicable. ORDER Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. Service connection for a heart condition is denied. Service connection for recurrent left arm pain is denied. An evaluation in excess of zero percent for hemorrhoids is denied. A 10 percent disability rating for right shin splint is granted, subject to controlling regulations applicable to the payment of monetary benefits. A 10 percent disability rating for left shin splint is granted, subject to controlling regulations applicable to the payment of monetary benefits. A 10 percent disability rating for bronchial asthma is granted, subject to controlling regulations applicable to the payment of monetary benefits. REMAND The medical evidence reflects that the veteran has abdominal pain. Also, the VA examinations reflected not address whether the veteran is taking medication, specifically birth control pills, to control the symptoms of the ovarian cyst and whether such medication is controlling symptomatology. See 38 C.F.R. § 7615 (2004). Accordingly, this case is remanded for the following: The AMC should schedule the veteran for VA examination to determine the current severity of the ovarian cyst. The examiner should address the following: (1) whether the abdominal pain is associated with the ovarian cyst; (2) whether the veteran is taking medication, to include birth control pills, to treat the ovarian cyst; and (3) if she is taking medication to treat the ovarian cyst, whether the symptomatology of the ovarian cyst is completely controlled, partially controlled, or not controlled at all by the use of medication. If upon completion of the above action the claim remains denied, the case should be returned after compliance with requisite appellate procedure. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans Benefits Act of 2003, Pub. L. No. 108-183, § 707(a), (b), 117 Stat. 2651 (2003) (to be codified at 38 U.S.C. §§ 5109B, 7112). ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs