Citation Nr: 9930464 Decision Date: 10/25/99 Archive Date: 10/29/99 DOCKET NO. 97-23 446A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for a respiratory disorder ("asthma"), a neurological disorder ("carpal tunnel syndrome"), right ear "earaches," and a swallowing disorder manifested by "sore throats," claimed to be the result of an undiagnosed illness. 2. Entitlement to an evaluation in excess of 20 percent for traumatic arthritis of the left ankle. 3. Entitlement to an evaluation in excess of 20 percent for traumatic arthritis of the cervical spine. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The veteran served on active duty from July 1974 to August 1995. During the course of a hearing before a member of the Board of Veterans' Appeals (Board) in October 1997, the veteran withdrew from consideration the issues of entitlement to service connection for irritable bowel syndrome and a liver disorder, as well as increased evaluations for service- connected arthritis of the lumbosacral spine and chronic fatigue syndrome. Accordingly, these issues, which were formally on appeal, are no longer before the Board. In a rating decision of June 1997, the Regional Office (RO) granted a 20 percent evaluation for service-connected traumatic arthritis of the cervical spine, previously evaluated as noncompensably disabling. The veteran voiced his disagreement with that determination, and the current appeal ensued. In March 1998, the veteran's case was REMANDED to the RO for additional development. Subsequent to the Board's remand, the RO, in a decision of March 1999, granted service connection for traumatic arthrosis of the right wrist, and an increased (20%) evaluation for impairment of the left ankle, effective from August 1, 1995. The case is now, once more, before the Board for appellate review. FINDINGS OF FACT 1. The claim for service connection for a chronic respiratory disorder, including asthma, is not supported by cognizable evidence showing that such a disability was present in service, or is otherwise of service origin. 2. The claim for service connection for right ear "earaches" is not supported by cognizable evidence showing that such a disability was present in service, or is otherwise of service origin. 3. The claim for service connection for a swallowing disorder manifested by "sore throats" is not supported by cognizable evidence showing that such a disability was present in service, or is otherwise of service origin. 4. The veteran does not have a wrist disability, claimed as a "neurological disorder," including carpal tunnel syndrome, which is of service origin. 5. The veteran's left ankle disability is currently productive of no more than a marked limitation of motion of the ankle in question, with no evidence of ankylosis. 6. The veteran's traumatic arthritis of the cervical spine approximates severe limitation of motion of that segment of the spine. CONCLUSIONS OF LAW 1. The claim for service connection for a chronic respiratory disorder, including "asthma," is not well grounded. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1998). 2. The claim for service connection for right ear "earaches" is not well grounded. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1998). 3. The claim for service connection for a swallowing disorder manifested by "sore throats" is not well grounded. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1998). 4. The claim for service connection for a wrist disability manifested as a "neurological disorder," including carpal tunnel syndrome, is not well grounded. 38 U.S.C.A. § 5107 (West 1991 & Supp. 1998). 5. An evaluation in excess of 30 percent for impairment of the left ankle is not warranted. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. §§ 4.40, 4.59, and Part 4, Codes 5270, 5271 (1998). 6. The manifestations of traumatic arthritis of the cervical spine warrant a 30 percent rating. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. §§ 4.7, 4.40, 4.59, and Part 4, Codes 5290, 5293 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background At the time of the veteran's service entrance examination in February 1974, he gave a history of asthma in early childhood, with no attacks for the past 10 years. Physical examination of the veteran's respiratory system conducted at that time was within normal limits, and no pertinent diagnosis was noted. In July 1975, the veteran was seen for a complaint, among other things, of a "sore throat." A physical examination was negative, though a throat culture showed evidence of Beta Strep, Group A. The clinical impression was "congestion." In a service clinical record of February 1977, it was noted that the veteran had been experiencing the "flu" for approximately two days, and that he was currently suffering from, among other things, a sore throat. On physical examination, the veteran's throat appeared red, but with no evidence of pus pockets. The clinical impression was viral syndrome. In September 1978, the veteran was heard to complain of, among other things, a sore throat. A physical examination conducted at that time revealed the presence of erythema and mild edema. The clinical assessment was rule out upper respiratory infection and streptococcal laryngitis. In June 1980, the veteran gave a history of a sore throat of two weeks' duration. On physical examination, the veteran's throat was red, with some evidence of exudate. Additionally noted was that the veteran's tonsillar pillars were minimally inflamed. The clinical assessment was pharyngitis. In April 1981, the veteran once again complained of, among other things, a sore throat. A physical examination of the veteran's throat conducted at that time was positive for the presence of reddened pustules. The clinical assessment was viral syndrome. In July 1984, the veteran was heard to complain of a sore throat and "ear pain." On physical examination, the veteran's ears were within normal limits. His throat was slightly inflamed bilaterally, though his lungs were clear. The clinical assessment was "common cold." In August 1985, the veteran complained of a problem swallowing. The clinical assessment was right intercostal neuralgia. A service clinical record dated in early March 1989 is to the effect that the veteran was seen at that time for, among other things, a sore throat, and shortness of breath. According to the veteran, his shortness of breath occurred when climbing a ladder. Physical examination revealed some redness of the veteran's tympanic membranes. Additionally noted were some redness and swelling of the throat, as well as wheezing upon inhalation and expiration. The clinical assessment was rule out upper respiratory infection. On clinical follow-up approximately three days later, the veteran gave a history of dyspnea on exertion or wheezing. Physical examination was significant for the presence of wheezes on forced expiration. The clinical impression was "normal." In December 1989, the veteran complained of pain in his ears. On physical examination, the veteran's tympanic membranes were somewhat cloudy, but reflective to light. There was no evidence of any uvular shift, or of exudate or pustules in the veteran's throat. The veteran's lungs were within normal limits. The clinical assessment was upper respiratory infection. In June 1991, the veteran was once again heard to complain of ear pain. When questioned, the veteran pointed to the area of his temporomandibular joint as the location for his ear pain. The veteran gave no history of sore throat, or of recurrent facial pain or asymmetry. On physical examination, the veteran's ears were clear, with intact tympanic membranes, and a good light reflex. The Valsalva maneuver was performed in a normal manner, and there was no evidence of either pre- or post auricular nodes. The veteran's mouth and throat were negative for the presence of pharyngeal erythema or exudate, and the mucosa were moist and pink. The clinical impression was "normal exam." In a service clinical record of August 1991, it was noted that the veteran had participated in Operation Desert Shield/Storm in both Kuwait and Northeast Saudi Arabia, and that his exposure included heavy oil with a high sulfur content, as well as oral pyridostigmine and light oil smoke. In late December 1991, the veteran complained of certain cold symptoms associated with a right earache. On physical examination, the veteran's throat was slightly red, but his lungs were clear. The clinical assessment was rule out sinus congestion. In January 1995, the veteran complained of a sore throat and difficulty swallowing. Physical examination was significant for the presence of a hyperemic oropharynx with some pustules, as well as positive anterior cervical lymphadenopathy bilaterally. At the time of examination, the veteran's lungs were clear. The clinical assessment was possible strep pharyngitis. Approximately two days later, it was noted that, following the veteran's treatment with antibiotics, he was "feeling much better." The clinical assessment was "subjectively improved," presumptive strep throat. In early February 1995, the veteran complained of a sore throat of two days' duration, accompanied by "painful swallowing." On physical examination, it was noted that the veteran had recently completed a course of antibiotics for presumed strep infection, but that his symptoms did not resolve. The veteran's throat was without pustules or exudate of the posterior oropharynx, though there was evidence of bilateral tonsillar edema, as well as a hyperemic posterior oropharynx. Additionally noted was the presence of both cervical and submandibular adenopathy. The clinical assessment was probable viral pharyngitis, rule out mono(nucleosis). During the course of evaluation by the battalion surgeon in February 1995, it was noted that, in January, the veteran had developed a clinically evident cervical lymphadenopathy and sore throat, but that strep cultures were negative. At that time, the veteran was placed on medication for a short course, with the result that his symptoms resolved. The veteran was subsequently evaluated with a mono spot test for mononucleosis, which was reported as negative. On physical examination, there was no evidence of any adenopathy. The veteran's throat and ears were within normal limits, and his chest displayed clear breath sounds bilaterally. Neurological evaluation was unremarkable, with normal musculoskeletal, motor and sensory findings. It was noted at the time of examination that the veteran displayed no discrete physical or laboratory findings. Radiographic studies of the veteran's chest conducted in March 1995 showed no significant abnormal findings. On service separation examination in late March 1995, the veteran gave a history of "on and off" wrist pain. Additionally noted were problems with recurrent pharyngitis, and "plugged ears." The veteran stated that he experienced some shortness of breath with heavy exercise, as well as occasional "wheezing." On physical examination, the veteran's lungs and chest were within normal limits, as was his neurologic system, his ears, and his throat. Radiographic studies of the veteran's chest were within normal limits. The pertinent diagnosis was "rule out asthma." On the day following the veteran's service separation examination, he was seen for, among other things, a history of wheezing on exertion. At the time of evaluation, the veteran gave a "long history" of allergic rhinitis since childhood, with recent intermittent dyspnea when running and, on occasion, nocturnally. Additionally noted were problems with recurrent sore throats, as well as "swollen nodes" the past few months. On physical examination, the veteran's throat was within normal limits. Examination of the veteran's lungs showed possible end expiratory wheezes. The clinical impression was allergic rhinitis and asthma. In early April 1995, the veteran was seen for follow-up of his asthma and allergic rhinitis. At the time of evaluation, the veteran stated that his lungs were "better." On physical examination, the veteran's lungs were clear with the exception of some end expiratory wheezes. The clinical impression was asthma and allergic rhinitis. In early June 1995, the veteran was heard to complain of pain in his wrists, in particular, while doing "normal things" around the house. More specifically, the veteran complained of bilateral wrist pain following housework and/or tire changing, or other actions requiring wrist motion. The veteran stated that he experienced numbness (but no tingling) in his right forearm and the back of his hand. Additionally noted were complaints of some weakness and/or trouble with the grip in both hands, somewhat worse on the left than the right. According to the veteran, his pain and/or weakness had begun two weeks ago. On physical examination, there was a "cold feeling" in both of the veteran's arms and hands, primarily consisting of problems with sensation in the hands. The veteran's wrists showed no evidence of crepitus, or of tenderness to palpation. Both Tinel's and Phalen's sign were negative. On neurological evaluation, there was decreased pinprick testing at the level of the 6th and 8th cervical vertebrae distribution in both upper extremities. There was normal light touch in both upper extremities, as well as a normal two-point discrimination in both hands to 5 millimeters. Muscle strength in both upper extremities was 5/5 and equal. The clinical assessment was bilateral nerve impairment of the upper extremities in a T1-T2 distribution; and overuse syndrome versus carpal tunnel syndrome of both wrists. During the course of a fire department physical conducted in early August 1995, it was noted that the veteran displayed "no abnormalities" with the exception of his posterior pharynx, which appeared to be healing satisfactorily from recent surgery for sleep apnea. On Department of Veterans Affairs (VA) neurologic examination in December 1995, the veteran gave a history of Bell's palsy, with a recurrence in January of 1995, at which time he experienced not only mild facial weakness, but right ear pain. Physical examination revealed the veteran's ears to be within normal limits. Fine motor coordination in the veteran's arms was, likewise, within normal limits, as was strength in all muscle groups. Sensory examination of the veteran's hands revealed no loss of sensation to touch, pain, temperature, or vibratory sense. Deep tendon reflexes were 2 plus and symmetrical throughout, and cerebellar testing was essentially normal. At the time of evaluation, it was noted that "in general" the veteran's neurologic examination was "entirely normal." VA pulmonary function testing conducted in December 1995 revealed normal spirometry, as well as a flow-volume loop of normal contour. In February 1996, a VA general medical examination was accomplished. At the time of evaluation, the veteran gave a history of intermittent shortness of breath with exercise since the summer of 1994. Reportedly, pulmonary function testing conducted in December 1995 was within normal limits. The veteran described the shortness of breath as a raspy feeling in the throat, with no bronchospasm, which occurred on heavy exercise or running. According to the veteran, this sensation would "come on" while running, and remain constant during the entire time he ran. The veteran further commented that he had experienced one episode of sore throat with swollen lymph nodes in December of 1994, and that, according to blood testing, this was apparently not a Streptococcus infection. According to the veteran, he had experienced repeated episodes of sore throat since that time, though with "no actual palpable lymph nodes." Additional complaints included pain in both wrists. In the veteran's opinion, his symptoms, in particular, his sore throat and breathing problems, had become "significantly worse" since 1995. On physical examination, the veteran's head, face and neck displayed no abnormality. His throat was, likewise, without abnormality, though there was evidence of a past tonsillectomy. Examination of the veteran's ears revealed normal tympanic membranes, with no evidence of clinical hearing loss. The respiratory system was entirely normal, with the veteran able to go up 2 or 3 flights of stairs, though with some shortness of breath "at the end of it." The veteran's neurologic symptoms showed no evidence of abnormalities of motor status, coordination, reflexes or sensation. The cranial nerves were likewise within normal limits. Radiographic studies of the veteran's wrists and chest were essentially unremarkable. The pertinent diagnoses were asthma by history, with episodes of shortness of breath on exertion, and normal pulmonary function tests; recurrent sore throats, the etiology of which was uncertain; and "pain in both wrists." In correspondence of July 1996, the veteran's private physician wrote that the veteran had undergone electromyographic and nerve conduction studies on both upper extremities, which had proven "unremarkable." In a private clinical record of early August 1996, it was noted that, while on examination, there was a slight slowing along the veteran's elbow and left ulna, this was considered within normal limits. Accordingly, there was "no evidence" of carpal tunnel syndrome. During the course of a private physical examination in November 1996, the veteran complained of shortness of breath on exertion, as well as "wheezing" when resting and "shallow breathing." According to the veteran, he at times became "tight in the chest," and unable to "get enough air." Reportedly, in 1995, he had undergone a tonsillectomy with removal of the uvula "for snoring." Currently, the veteran was utilizing two separate inhalers, though he had not used "any inhalations over the past week." On physical examination, the veteran's throat appeared clear. There was evidence that his uvula had been removed, and that, on a prior occasion, he had undergone a tonsillectomy. The veteran's chest was clear to percussion and auscultation both before and after exercise. Pre- and post spirometry performed both before and after exercise revealed no evidence of exercise-induced bronchospasm. The veteran performed a good exercise test, and his heart rate went up to 130. In the opinion of the examiner, there was no evidence of exercise-induced asthma. Nor did the veteran require treatment with inhalers. In November 1996, a VA orthopedic examination was accomplished. At the time of examination, the veteran gave a history of a left ankle sprain in 1983, following which his ankle had "never been normal." According to the veteran, he experienced pain anterolaterally, accompanied by some thickness, and chronic swelling, and, on occasion, even more swelling. Additionally noted were problems with bilateral wrist pain beginning in March 1995, as well as a "sore throat." On physical examination, there was no evidence of overt instability either in talar tilt or on Drawer sign. There was a large hard callosity under the 2nd and 3rd metatarsal heads, apparently from lack of dorsiflexion of the left ankle. Range of motion measurements showed dorsiflexion to 35 degrees, with plantar flexion to 30 degrees, eversion of 5 degrees with pain, and inversion of 15 degrees, accompanied by pain and some crepitus. Radiographic studies of the left ankle showed severe post-traumatic changes medially, as well as a probable osteochondritis dissecans lesion laterally from prior trauma. The pertinent diagnosis was post-traumatic arthritis of the left ankle, moderately severe, with a probable loose body. During the course of a private rehabilitation consultation in early December 1996, the veteran gave a history of bilateral wrist pain, in particular, on exertion or with activity involving weightlifting. On neurological evaluation, there was a positive tenderness over the left cubital tunnel, as well as a positive Tinel's sign. The veteran displayed a full range of motion of his extremities bilaterally, though with pain in the wrist, especially with flexion and extension. There was a negative Phalen's, as well as a negative Tinel's sign at the wrist. Motor strength in the veteran's upper extremities was "roughly 5/5," and sensation was intact to pinprick and light touch. The clinical impression was rule out ulnar neuropathy/in the cubital tunnel/wrist tendinitis/subacromial bursitis. On VA neurological examination in March 1997, the veteran gave a history of numbness on the right side of his neck which began in his right ear, and was of variable duration. Additionally noted were problems breathing since his exposure to oil smoke in the Persian Gulf. On physical examination, the veteran's tympanic membranes were within normal limits. His palate elevated in a symmetrical fashion, and his tongue was in the midline without fasciculations. Motor examination showed 5/5 strength in both upper extremities, with normal tone and bulk. Tests of pronator drift were negative, and sensory examination was normal to light touch, temperature, and vibration. Muscle stretch reflexes were 2 plus and symmetrical in both of the veteran's arms. Radiographic studies of the chest and left wrist were within normal limits, and no pertinent diagnoses were noted. On VA medical examination in April 1997, it was noted that the veteran's claims folder was available, and had been reviewed. The veteran complained of pain in both of his wrists, and of weakness in his right arm, and stated that his symptoms had not changed since his original examination. The veteran additionally complained of pain in the area of his neck. Reportedly, the veteran had once been diagnosed with asthma, but this had resolved, and he no longer experienced any symptoms of asthma. He did, however, complain of exhaustion at the end of a busy day. The veteran stated that, at the end of the day, he was somewhat short of breath, and was particularly short of breath were he to climb more than three flights of stairs. On physical examination, the veteran stated that he experienced no cough on a regular basis, but occasionally, "brought up white mucus." He once again noted problems with shortness of breath at the end of the day. The veteran's heart and chest were within normal limits, and there were no adventitious sounds in the chest. Musculoskeletal evaluation showed a full range of motion for both wrists. Range of motion measurements for the cervical spine showed flexion and extension to 20 degrees, with lateral flexion to 30 degrees and rotation to 45 degrees. It was noted that passive movements of the veteran's neck did result in some pain. Range of motion measurements for the veteran's left wrist showed dorsiflexion from 0 to 70 degrees, with palmar flexion from 0 to 80 degrees, radial deviation from 0 to 20 degrees, and ulnar deviation from 0 to 45 degrees. According to the examining physician, the veteran displayed a "negative examination" of the wrists. Additionally noted was that the veteran's asthma had "resolved according to the veteran." A private clinical record dated in May 1997 is to the effect that the veteran was seen at that time for a "sore throat." At the time of evaluation, the veteran complained of throat irritation of approximately three days' duration. Physical examination revealed a white excoriation in the area of the right tonsil, which was eroded, and apparently herpetic in nature. The clinical assessment was herpes stomatitis. During the course of a private rehabilitation consultation in June 1997, the veteran complained of, among other things, bilateral wrist pain. Reportedly, since the time of the veteran's tour of duty in the Gulf War, he had experienced numerous muscle and joint aches, as well as pain, and marked discomfort. On neurological evaluation, the veteran displayed bilateral wrist pains, as well as aches and a numbness extending into his hands. Motor strength was 5/5, and deep tendon reflexes were 1+ with intact sensation. The pertinent diagnosis was wrist tendinitis. A private clinical record dated in early August 1997 is to the effect that the veteran was seen at that time with complaints of a sore throat and earaches "on the left side only." On physical examination, the veteran's ears were bilaterally equal and patent, with a good light reflex. His throat was normal, though there was a slight tenderness along the left Eustachian line. The clinical assessment was probable left Eustachian tube dysfunction. Slightly more than one week later, the veteran was seen for follow-up of left Eustachian tube dysfunction. Noted at that time was that the veteran had been complaining of difficulty with swallowing. On physical examination, the veteran's ears were once again bilaterally equal and patent, with a good light reflex. The nose and throat were similarly within normal limits. On auscultation of the larynx, there was no evidence of any impediment, and the veteran's chest was clear. The clinical assessment was probable global hystericus. Private rehabilitation consultations dated in August and September 1997 reflect a clinical assessment of wrist tendinitis. Private radiographic studies of the veteran's cervical spine conducted in October 1997 were consistent with mild disc space narrowing at the level of the 5th and 6th cervical vertebrae, with associated mild hypertrophic degenerative changes. Additionally noted was the presence of diminished cervical lordosis, with an otherwise normal cervical spine. In correspondence from the veteran's private physician received in October 1997, it was noted that the veteran had been his patient since December 1996, and that he had been treated for, among other things, bilateral wrist pain. On neurological evaluation of the cervical spine, the veteran displayed decreased rotation due to muscle guarding in the anterior trapezius group on the right, with trigger points through the right shoulder and into the posterior deltoid. Additionally noted was some tenderness on the supraspinatus tendon insertion on the right. There was crepitance present in both wrists, though with a full range of motion. The pertinent diagnoses were wrist tendinitis and cervical strain. During the course of a private physical medical consultation in October 1998, it was noted that the veteran's motor grip strength was approximately 40 kilograms of pressure bilaterally, and that there was marked pain over the extensor tendons of both wrists. In early January 1999, an additional VA neurologic examination was accomplished. At the time of examination, the veteran stated that, since the time of his service in the Gulf War, he had suffered from sore wrists and arms which he related to "carpal tunnel syndrome." The veteran described no paresthesia or pain in the distribution compatible with median nerve involvement, instead complaining that, when he attempted to extend his wrist, he experienced an ache in the wrist joint. On physical examination, the veteran displayed completely normal motor and sensory functions, including light touch and pain modalities throughout his upper extremities. Motor examination was 5/5 throughout, and reflexes in the upper extremities were both normal and symmetrical. The examiner commented that he could find no evidence either by history or on examination of anything to indicate the presence of carpal tunnel syndrome. Further noted was that, if anything, the veteran was suffering from degenerative joint disease with associated "arthritis," aches, and pains at the wrists and elbows. Also in early January 1999, the veteran underwent a VA Gulf War examination. At the time of evaluation, it was noted that the veteran's "condition" was reportedly due to an "undiagnosed illness." The veteran stated that he was involved in the Gulf War from December of 1990 to August of 1991, at which time he participated in the advance from Saudi Arabia through the Kuwait oil fields, and on to the Kuwait City Airport. The veteran stated that he had direct contact with prisoners of war, but sustained no injuries. According to the veteran, there were no chemical, biological, or radiological alarms. While the veteran received various vaccines, he was unaware whether he had received the anthrax vaccine. The veteran did receive pyridostigmine, and believed he additionally received antimalarial medication. During the course of evaluation, the veteran stated that he had developed exercise-induced asthma in 1994 while in the service, at which time he was placed on Cromolyn Sodium inhaler. Reportedly, the veteran was running 9 miles a day, and what would normally be a 19-minute 3-mile run went up to 26 minutes. The veteran stated that he received "no reasonable benefit" from the aforementioned Cromolyn Sodium, but nonetheless continued using the medication. According to the veteran, he at times felt some tightness in his chest, at which time he would usually sit down, and use his Albuterol inhaler. This usually resulted in some relief within 2 to 3 minutes. The veteran stated that, in 1995, he had undergone a tonsillectomy and uvulopalatectomy in order to rid him of a snoring problem, and to alleviate fatigue. While this did relieve the veteran's snoring, it did not alleviate his fatigue. The veteran acknowledged a certain frustration with his current problems, being particularly frustrated by his inability to perform certain leisure activities, or to "have full stamina to do regular everyday activities." The veteran stated that he experienced no reduction in activities of daily living, and was otherwise functioning well in his work. On physical examination, the veteran's nose and ears were within normal limits. His throat showed some evidence of residuals of his past uvulopalatectomy. There was no evidence of thyromegaly or lymphadenopathy, and his lungs were clear to both auscultation and percussion. Foot flexion and extension were within normal limits, with a right-sided dominance. Reflexes in the lower extremities were 2+ for the patellar and ankle, and motor strength, other than right- sided dominance, was symmetrical at 4/5 on the left and at 5/5 on the right. The clinical impression was of no pulmonary disease by X-ray and pulmonary function testing; and absence of right ear and throat pathology. On VA orthopedic examination in mid-January 1999, it was noted that the veteran's claims folder had been reviewed. The veteran complained of problems with his left ankle since 1983, at which time he had suffered a sprain. Current complaints included consistent inability to demonstrate full range of motion of the ankle, as well as ankle pain. The veteran stated that he typically wore leather shoes, with resulting callosities over the ball of his foot. Current symptoms relative to the ankle included lateral swelling and a feeling of giving way when walking on uneven ground. The veteran denied any impact on his job performance, but stated that his recreational activity was affected, in particular, by his being unable to tolerate ambulation on uneven ground. The veteran utilized no orthotics or medication, and denied any problems with "flare-ups." Physical examination of the veteran's left ankle confirmed a range of motion of minus 5 degrees of flexion actively and zero degrees passively, with plantar flexion of 45 degrees actively and passively. There was pronation of the veteran's hindfoot of 5 degrees actively and passively, as well as supination of 30 degrees actively and passively. The veteran displayed a markedly tight Achilles tendon, which prevented ankle dorsiflexion even on a passive basis, both with the knee fully extended and with the knee flexed. Radiographic study of the veteran's left ankle failed to demonstrate any significant bony abnormality. The clinical impression was Achilles tendon contracture of the left ankle, secondary to treatment of a previous ankle sprain which occurred in the service. On VA examination of the cervical spine, likewise conducted in mid-January 1999, it was noted that the veteran's claims folder had been extensively reviewed prior to examination. Medical records showed no history of injury or previous surgery, but rather a spontaneous gradual onset of discomfort with extremes of motion, especially on head turning. The veteran's symptoms included pain with marked flexion, touching the chin to the chest, and difficulty looking to the rear when driving an automobile. He denied weakness, swelling, induration, erythema, heat, fatigability, or any loss of endurance or constitutional symptoms. The veteran's occupation was that of a laboratory supervisor, and he denied any job performance effect due to his cervical spine symptomatology. Present and past treatments reportedly included nonsteroidal anti-inflammatory medication. The veteran denied any flare-ups, and stated that his cervical pain continued unchanged "on a persistent basis." On physical examination, there was no evidence of any erythema or induration. Cervical symmetry was present in both front-to-back and side-to-side views. The veteran showed no evidence of tenderness to palpation, and no weakness was in evidence. There was no swelling, induration or deformity, and no fatigability with motion or muscle spasm. The veteran's musculature showed 5/5 responses to static testing, with neurologic evaluation showing normal motor and sensory responses in the upper extremities. Deep tendon reflexes were physiologic and symmetrical, and no postural abnormalities were noted. Range of motion studies of the cervical spine showed flexion to 45 degrees actively and to 60 degrees passively; extension to 30 degrees actively and to 70 degrees passively; a right tilt to 25 degrees actively and to 45 degrees passively; a left tilt to 25 degrees actively and to 45 degrees passively; right rotation to 55 degrees actively and to 70 degrees passively; and left rotation to 55 degrees actively and to 60 degrees passively. Radiographic studies of the cervical spine showed a slight narrowing and mild anterior C5 osteophyte formation of both the C4/5 and the C5/6 discs, especially on lateral view. Loss of normal curvature of cervical lordosis was likewise seen. The pertinent diagnosis was mild cervical spondylosis, with no evidence of radiculopathy. Analysis I. Entitlement to Service Connection for a Respiratory Disorder ("Asthma"), a Neurological Disorder ("Carpal Tunnel Syndrome"), Right Ear "Earaches," and a Swallowing Disorder Manifested by "Sore Throats," Claimed to be the Result of an Undiagnosed Illness. As to those issues before the Board involving service connection, the threshold question which must be resolved is whether the veteran's claims are well grounded. See 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim is a plausible claim, meaning a claim which appears to be meritorious. See Murphy, 1 Vet. App. 81. A mere allegation that a disability is service connected is not sufficient; the veteran must submit evidence in support of his claims which would "justify a belief by a fair and impartial individual that the claim is plausible." 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for a claim to be well grounded, there must be competent evidence of current disability (medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the inservice injury or disease and the current disability (medical evidence). See Caluza v. Brown, 7 Vet. App. 498 (1995); see also Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); Heuer v. Brown, 7 Vet. App. 379 (1995); Grottveit v. Brown, 5 Vet. App. 91 (1993). The second and third elements of this equation may also be satisfied under 38 C.F.R. § 3.303(b) (1998), by (a) evidence that a condition was "noted" during service or during an applicable presumptive period; (b) evidence showing postservice continuity of symptomatology; and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post service symptomatology. See 38 C.F.R. § 3.303(b) (1998); Savage v. Gober, 10 Vet. App. 488 (1997). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of (i) the existence of a chronic disease in service or during an applicable presumptive period and (ii) present manifestations of the same chronic disease. Ibid. For the purpose of determining whether a claim is well grounded, the credibility of the evidence in support of the claim is presumed. See Robinette v. Brown, 8 Vet. App. 69 (1995). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 1998). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1998); 38 C.F.R. §§ 3.307, 3.309 (1998). On November 2, 1994, Congress enacted the "Persian Gulf War Veterans' Benefits Act," Title I of the "Veterans' Benefits Improvements Act of 1994," Public Law 103-446. That statute added a new § 1117 to Title 38, United States Code, authorizing the VA to compensate any Persian Gulf veteran who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses which became manifest either during active duty in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more within a presumptive period following service in the Southwest Asia Theater of Operations during the Persian Gulf War. To implement the Persian Gulf War Veterans' Act, the VA added 38 C.F.R. § 3.317 which defines qualifying Persian Gulf service, as well as establishing the presumptive period for service connection, and a broad but nonexclusive list of signs or symptoms which may be representative of undiagnosed illnesses for which compensation may be paid. These "signs or symptoms" include fatigue; signs or symptoms involving skin; headache; muscle pain; joint pain; neurologic signs or symptoms; neuropsychological signs or symptoms; signs or symptoms involving the upper or lower respiratory system; sleep disturbances, gastrointestinal signs or symptoms; cardiovascular signs or symptoms; abnormal weight loss; and menstrual disorders. On March 6, 1998, the presumptive period for undiagnosed illnesses was extended to December 31, 2001. See 63 Fed. Reg. 11,122-11,123 (March 6, 1998). For purposes of § 3.317, the disability in question cannot be attributable to any known clinical diagnosis. Objective indications of chronic disability include both "signs" in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators which are capable of independent verification. Compensation may not be paid where there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event which occurred between the veteran's most recent departure from active duty in the Southwest Asia Theater of Operations during the Persian Gulf War and the onset of the illness, or if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317 (1998). On the issue of service connection for a neurological disorder, claimed as "carpal tunnel syndrome," the veteran's wrist abnormalities have been attributed to tendonitis or arthritis, not to an undiagnosed disability or to any neurological disorder. Carpal tunnel syndrome has not been established. The record does not support a conclusion that the veteran has a neurological or neurological-like disability of either wrist. It follows that he does not have an undiagnosed disorder of the wrists manifested by neurological abnormalities. On the issues of service connection for a respiratory disorder ("asthma"), recurrent and chronic right ear "earaches," and a swallowing disorder characterized by "sore throats," the veteran has expressed his belief that such problems are due to his participation in the Persian Gulf War. However, as noted above, an award of compensation is indicated only where it is shown that the veteran exhibits objective indications of chronic disability resulting from an undiagnosed illness or combination of undiagnosed illnesses which became manifest either during active duty in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more within a presumptive period following service in the Southwest Asia Theater of Operations during the Persian Gulf War. 38 C.F.R. § 3.317 (1998). While in the case at hand, the veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, there is no indication that, during such service, or at any time thereafter, he suffered from an "undiagnosed illness" or combination of illnesses leading to chronic disability. To the extent that, while in service, the veteran received treatment for what was at that time described as "asthma," he did not, in fact, suffer from an "undiagnosed illness." Moreover, following a rather extensive private examination in November 1996, there was no evidence of any exercise-induced asthma, nor was it felt that the veteran had any need for inhalation therapy. On recent VA Gulf War examination in January 1999, the veteran's lungs were clear to both auscultation and percussion, and there was no evidence of pulmonary disease either by radiographic studies or pulmonary function testing. Based on such findings, the Board is of the opinion that the veteran exhibits no objective indications of chronic respiratory disability resulting from an undiagnosed illness or combination of undiagnosed illnesses. Nor is it demonstrated that the veteran at present suffers from a chronic respiratory disorder of any kind. Under such circumstances, his claim for service connection is not well grounded, and must be denied. Regarding the remaining issues of service connection for chronic right ear "earaches" and a swallowing disorder manifested by "sore throats," the Board observes that, while in service, the veteran did, in fact, receive treatment for ear pain and, on a number of occasions, for sore throats. However, on no occasion was it demonstrated that the veteran's complaints of "ear pain" were in any way indicative of the presence of chronic ear pathology. His "sore throats," while recurrent, were in all cases responsive to treatment with antibiotics, and likewise resulted in no chronic disability. At the time of the veteran's service separation examination in March 1995, there was no evidence of any chronic ear pathology, or of chronic throat pathology resulting in difficulty swallowing. Nor has it at any time been shown that the veteran presently suffers from chronic ear pathology, or a chronic throat disability. As noted above, there is no indication that the veteran has in the past or at any time following service suffered from an "undiagnosed illness." Nor is it currently demonstrated that the veteran suffers from chronic "earaches" or throat pathology which are in any way the result of "undiagnosed illness." Rather, as of the time of the aforementioned VA Gulf War examination in January 1999, there was no evidence whatsoever of either right ear or throat pathology. As noted above, in order for a claim to be well grounded, there must at a minimum be competent evidence of current disability. See Caluza v. Brown, 7 Vet. App. 498 (1995). Absent current evidence of chronic right ear pathology (other than hearing loss, for which service connection is already in effect), or of chronic pathology of the throat, the veteran's claims for service connection for those disabilities are not well grounded, and must be denied. II. Entitlement to Increased Evaluations for Impairment of the Left Ankle and Traumatic Arthritis of the Cervical Spine. In addition to the above, the veteran in this case seeks increased evaluations for his service-connected left ankle disability, and for traumatic arthritis of the cervical spine. In that regard, disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1998); 38 C.F.R. Part 4 (1998). In evaluating the severity of a particular disability, it is essential to consider its history. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1, 4.2 (1998). However, where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Finally, it is the intent of the Schedule for Rating Disabilities to recognize painful motion with joint or periarticular pathology as productive of disability. 38 C.F.R. § 4.59 (1994). This is to say that, even absent a definable limitation of motion, where there is functional disability due to pain, supported by adequate pathology, compensation may be warranted. 38 C.F.R. § 4.40 (1994); see also DeLuca v. Brown, 8 Vet. App. 202 (1995). In the present case, service connection is in effect for impairment of the left ankle, apparently the result of an inservice injury in October 1983. Service connection and a 10 percent evaluation for the veteran's left ankle disability was made effective from August 1, 1995, considered at the time to be the date following the veteran's discharge from service. In Fenderson v. West, No. 96-947 (U.S. Vet. App. Jan. 20, 1999), it was held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In Fenderson, the United States Court of Appeals for Veterans Claims also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal. No issue as to "staged" ratings arises in this case, however, inasmuch as the 20 percent evaluation currently in effect was made effective as of the date following the veteran's discharge from service. The Board observes that, on VA orthopedic examination in November 1996, there was no evidence of any overt instability of the veteran's left ankle. Dorsiflexion was to 35 degrees, with plantar flexion to 30 degrees. On more recent VA Gulf War examination in January 1999, ankle flexion and extension, as well as flexion and extension of the veteran's foot were described as within normal limits. On VA orthopedic examination, likewise conducted in January 1999, the veteran complained of a lack of full range of motion of his left ankle, and of ankle pain. Physical examination confirmed a range of motion of minus 5 degrees of flexion actively and 0 degrees passively, with plantar flexion of 45 degrees actively and passively. It was noted that the veteran had a markedly tight Achilles tendon, which prevented ankle dorsiflexion, even for passive motion, both with the knee fully extended and with the knee flexed. The Board observes that the 20 percent evaluation currently in effect contemplates the presence of a marked limitation of motion of the veteran's service-connected left ankle. This is the maximum schedular evaluation available for a service- connected ankle based on limitation of motion. 38 C.F.R. Part 4, Code 5271 (1998). The veteran's representative has argued that the veteran's service-connected left ankle disability is more properly evaluated pursuant to the provisions of 38 C.F.R. Part 4, Code 5270, that is, on the basis of ankylosis of the ankle. In that regard, an increased evaluation would require demonstrated evidence of a fixation of the veteran's left ankle in plantar flexion between 30 and 40 degrees, or in dorsiflexion between 0 and 10 degrees. 38 C.F.R. Part 4, Code 5270 (1998). While it is true that, at the time of the aforementioned examinations in January 1999, there was some conflict as to the exact degree of impairment of the veteran's service-connected left ankle, under no circumstances could the veteran's left ankle be viewed as ankylosed (which is to say, "fixed.") Nor was there any evidence of "flare-ups" involving the left ankle. Based on such findings, the Board is of the opinion that the 20 percent evaluation currently in effect is appropriate, and that an increased rating is not warranted. As it is not shown that current manifestations of the veteran's service- connected left ankle more nearly approximate the criteria for an increased evaluation than the evaluation currently in effect, the provisions of 38 C.F.R. § 4.7 (1998) are not for application. Accordingly, the Board is unable to reach a favorable determination in this matter. Finally, turning to the issue of an increased evaluation for the veteran's service-connected arthritis of the cervical spine, the Board notes that the 20 percent evaluation currently in effect was initially made effective from August 1, 1995, considered to be the date following the veteran's discharge from service. Accordingly, there is once again no need for the application of "staged" ratings. See Fenderson v. West, No. 96-947 (U.S. Vet. App. Jan. 20, 1999). At the time of the aforementioned VA examination in April 1997, range of motion of the veteran's cervical spine showed flexion from 0 to 20 degrees, with extension likewise from 0 to 20 degrees, lateral flexion to 30 degrees, and rotation to 45 degrees, accompanied by pain. On more recent VA examination in January 1999, it was noted that there was no history of injury, but rather a spontaneous gradual onset of discomfort with extremes of motion, especially head turning. The veteran denied both weakness and swelling, and likewise denied the presence of induration, erythema, heat, fatigability, or loss of endurance. At the time of evaluation, the veteran denied any job performance effect due to his cervical spine pathology. His primary concern revolved about his ability to perform recreational activities. The veteran stated that he had received no therapy, and did not utilize an orthotic. He likewise denied the presence of flare-ups, stating that his cervical pain continued unchanged "on a persistent basis." A physical examination of the veteran's cervical spine was negative for the presence of erythema or induration. While there was some stiffness and pain in the extremes of motion, there was no evidence of tenderness to palpation, or of any weakness. No swelling, induration, or deformity were in evidence, nor was there any fatigability with motion or muscle spasm. Range of motion measurements showed active flexion to 45 degrees, with extension to 30 degrees, right and left tilt to 25 degrees, and right and left rotation to 55 degrees. The clinical assessment was mild cervical spondylosis, with no evidence of radiculopathy. The Board notes that the 20 percent evaluation currently in effect contemplates the presence of moderate limitation of motion of the cervical segment of the spine. 38 C.F.R. Part 4, Code 5290 (1998). In order to warrant an increased evaluation, there would, of necessity, need to be demonstrated the presence of severe limitation of motion of the cervical spine, or, in the alternative, severe intervertebral disc syndrome, with recurring attacks, and only intermittent relief. 38 C.F.R. Part 4, Codes 5290, 5293 (1998). The examiner, however, did make the point that the veteran had stiffness and painful motion at the extremes of motion. In view of the differences between active and passive ranges and with application of 38 C.F.R. § 4.7, the veteran as a practical matter probably has greater than moderate loss of neck motion. ORDER Service connection for a respiratory disorder ("asthma") is denied. Service connection for right ear "earaches" is denied. Service connection for a swallowing disorder manifested by "sore throats" is denied. Service connection for a wrist disability attributable to an undiagnosed illness is denied. An evaluation in excess of 20 percent for service-connected impairment of the left ankle is denied. An evaluation of 30 percent for service-connected traumatic arthritis of the cervical spine is granted. John E. Ormond, Jr. Member, Board of Veterans' Appeals