Citation Nr: 0012110 Decision Date: 05/08/00 Archive Date: 05/18/00 DOCKET NO. 92-09 991 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana THE ISSUES 1. Whether new and material evidence has been submitted to reopen the claim of service connection for a right knee disorder, to include arthritis. 2. Whether new and material evidence has been submitted to reopen the claim of service connection for a left arm and hand disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD Scott Craven INTRODUCTION The veteran had active military service from September 1971 to October 1982. In April 1987, the Regional Office (RO), in pertinent part, denied the veteran's claims of service connection for a right knee disorder, a left arm disorder, and a heart disability. The veteran was notified of this determination, but did not file a timely appeal. In August 1989, the RO, in pertinent part, denied the veteran's claims of service connection for a right knee disorder, arthritis of the right knee, a heart disability, ulcers, and left arm disorder. The veteran was notified of this determination, but did not file a timely appeal. In a January 1991 decision of the RO, which, in pertinent part, denied the veteran's claims of service connection for a right knee disorder, arthritis of the right knee, heart disability, ulcers, a right hand disability, and a left arm disorder on the merits, apparently having reopened them on the basis of new and material evidence. The veteran appealed these issues to the Board of Veterans' Appeals (Board). In August 1994, the Board concurred that the issues of service connection for a right knee disorder, arthritis of the right knee, heart disability, ulcers, and a right hand disability were reopened and remanded the case for further development to include the issuance of a statement of the case as to the issue of service connection for a left arm disorder. Thereafter, the veteran was issued a statement of the case on that issue and he perfected his appeal. In October 1996, the veteran withdrew his appeal as to his claims of service connection for ulcers and a right hand disability. In April 1998, the Board indicated that the issues remaining in appellate status were entitlement to service connection for right hand, heart, and left arm disabilities. The Board again remanded the case for further development. The Board notes that, in April 1999, the RO granted service connection for a cardiovascular disorder with a 30 percent rating, effective on January 17, 1989. Thus, the matter of service connection for that issue was resolved. The veteran did not file a Notice of Disagreement to this action and, therefore, it is not a matter in appellate status before the Board at this time. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). The Board also notes that, in Barnett v. Brown, 8 Vet. App. 1, 4 (1995); aff'd 83 F.3d 1380 (Fed. Cir. 1996), the United States Court of Appeals for Veterans Claims (Court) held that the new and material evidence requirement is a material legal issue which the Board has a legal duty to address, regardless of the RO's actions. Thus, the Board will first address the issues as characterized on the title page herein, namely whether new and material evidence has been submitted to reopen the veteran's claims of service connection for a right knee disorder, to include arthritis, and for a left arm and hand disorder. The Board lastly notes that in a January 2000 rating decision, entitlement to a total disability rating based on individual unemployability was denied. The veteran has not initiated an appeal as to this issue. FINDINGS OF FACT 1. All relevant evidence for an equitable disposition of the veteran's appeal has been obtained. 1. In an August 1989 decision, the RO denied entitlement to service connection for a right knee disability to include arthritis and for a left arm disability and was provided notice of his procedural and appellate rights; however a notice of disagreement was not received within the subsequent one-year period. 3. Evidence submitted since the RO's August 1989 decision is so significant that it must be considered in order to fairly decide the merits of the claims of service connection for a right knee disorder, to include arthritis, and for a left arm and hand disorder. 4. There is no competent medical evidence establishing a causal relationship between any post-service right knee disability and his service-connected left knee disability nor is there competent medical evidence of a nexus between any post-service right knee disability and service. 5. The veteran clearly and unmistakably had a left arm and hand disability prior to his entry into active duty. 6. The veteran's left arm and hand disorder is shown as likely as not to have undergone an increase in severity beyond normal progression during service. CONCLUSIONS OF LAW 1. The RO's August 1989 decision denying service connection for a right knee disability to include arthritis and for a left arm disability is final. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. 3.104 (1999). 2. New and material evidence has been submitted to reopen the veteran's claim of service connection for a right knee disorder, to include arthritis. 38 U.S.C.A. §§ 1110, 1131, 5107, 5108, 7104, 7105 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.104(a), 3.156(a) (1999). 2. New and material evidence has been submitted to reopen the veteran's claim of service connection for a left arm and hand disorder. 38 U.S.C.A. §§ 1110, 1131, 5107, 5108, 7104, 7105 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.104(a), 3.156(a) (1999). 3. A well-grounded claim of service connection for a right knee disorder, to include arthritis, has not been presented. 38 U.S.C.A. §§ 1110, 1131, 5107, 7104 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.310 (1999). 4. Clear and unmistakable evidence that a left arm and hand disability existed prior to service exists, and the presumption of soundness is rebutted. 38 U.S.C.A. § 1111 (West 1991). 5. The veteran's left arm and hand disability is due to disease or injury which was aggravated in service. 38 U.S.C.A. §§ 1110, 1131, 5107, 7104 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background In an August 1989 decision, the RO denied entitlement to service connection for a right knee disability to include arthritis and for a left arm disability and was provided notice of his procedural and appellate rights; however a notice of disagreement was not received within the subsequent one-year period. The RO's August 1989 decision denying service connection for a right knee disability to include arthritis and for a left arm disability is final. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. 3.104 (1999). In connection with the August 1989 rating decision, the RO considered evidence including the veteran's service medical records; an April 1985 VA examination; private medical records from Ellen L. Parris, M.D., reflecting treatment from October 1986 to December 1986; private medical records from Northland Orthopedic Association, reflecting treatment in October 1986, private medical records from Sacred Heart-St. Mary's Hospital, reflecting treatment from June 1986 to October 1986; private medical records from Rhinelander Medical Center, reflecting treatment from September 1986 to January 1987; private medical records from Lafayette Home Hospital, reflecting treatment from January 1985 to February 1986; private medical records from St. Elizabeth Hospital Medical Center, reflecting treatment from December 1983 to March 1986; a January 1987 VA examination; private medical records from Wright State University, reflecting treatment from May 1987 to May 1989; private medical records from Marvin C. Vice, D.O., reflecting treatment in September 1988; a July 1989 VA examination; and lay statements by the veteran. A careful review of the service medical records shows that, on entrance examination in September 1971, the veteran's upper and lower extremities were reported to be clinically normal. The veteran was reported to have had a fracture of the left arm with no current problems. In September 1973, he was reported to have had several episodes of numbness of the distal left upper extremity over the previous one and a half years. He was reported to have a history of fracture of the upper radius six and a half years before. An x-ray study of the left radius was reported to be negative and he was diagnosed with possible nerve entrapment. In September 1974, the impression was stocking glove sensory loss of the left forearm with decreased grip strength. In January 1975, the veteran was reported to have sustained a fracture of the left radius approximately five years before. A malunion was reported to have occurred. He was reported to have had difficulties with loss of motion and pain in his forearm. He was reported to have marked limitation of supination of the arm, limited to only about 10 degrees. The fracture/malunion was reported to be felt to butt against the ulna in supination. The veteran was reported to have undergone an osteotomy of the radius with compression plating. In January 1976, the veteran was reported to have dropped a bed on his left arm at a warehouse. He was reported to have swelling, redness and pain on movement. An x-ray study revealed that there was an orthopedic plate seen through the proximal radius, which should relate to old trauma. There was reported to be no evidence of acute fracture. In November 1976, the veteran was reported to have had an open osteotomy that went on to a nonunion in spite of three months of plaster immobilization. He was reported to have had a re- exploration in June 1975 in addition to bone grafting with compression plating. He was reported to have had healing of the radius with persistent forearm pain and limitation of supination at time of admission, with no supination beyond neutral position. He was reported to have underwent surgery for removal of internal fixation and was diagnosed with status post compression plating of left radius. On hospital records, reflecting treatment form March 1978 to April 1978, the veteran was reported to have a history of recurrent lateral dislocations of the left patella. He was diagnosed with subluxing patella and chondromalacia patella. In December 1978, the veteran was reported to have hit his left elbow three times in the course of a fall in his bathroom at home. He was reported to complain of decreased range of motion. X-ray studies revealed evidence of healed proximal radial fracture and no new injuries were reported to be identified. The veteran was assessed with a bruise. In May 1981, the veteran reported that his arm was very tender and that it hurt to move his hand. X-ray studies revealed that no gross fracture was noted and the veteran was assessed with rule out fracture of the ulna and radius and rule out contusion. In December 1981, the veteran was reported to have progressive knee pain. He complained of bilateral chondromalacia of the patella and degenerative arthritis of both knees. He was reported to have had realignment of the left knee in 1978. The impression was overuse (jumper's knee). X-ray studies of both knees revealed a normal examination. In March 1982, the veteran was reported to have a history of recurrent bilateral knee pain surgery on the left knee for chondromalacia patella. He was also reported to have a history of degenerative arthritis of both knees, left greater than right. A provisional diagnosis was chondromalacia patella and degenerative arthritis of the left knee. An x-ray study was reported to reveal degenerative changes and the veteran was assessed with left chondromalacia patella. On VA examination in January 1983, the veteran was reported to have slight atrophy of the left forearm, but little, if any, detectable weakness of the left hand, wrist or elbow. Range of motion of all parts was reported to be normal, although there was no supination. The veteran's injury was reported to have occurred in 1968. He was diagnosed, in part, with postoperative residuals of injury of the left knee and left forearm. An x-ray study of the left forearm revealed evidence of an old fracture of the proximal radial diaphysis. Osteotomy defects and callus formation were also reported to be seen. In October 1986, private medical records from Rhinelander Medical Center reported that the veteran had recently fell on his left hand and felt a popping sensation. An x-ray study was reported to show no fracture. In October 1986, a private medical record from Sacred Heart- St. Mary's Hospital revealed an impression of no definite fracture and decreased density of bony structures with arthritic changes in the left wrist. On private medical records from Northland Orthopedic Associates, reflecting treatment from October 1986 to November 1986, the veteran was reported to complain of problems with his left knee and left arm. He was reported to complain of numbness in the ulnar aspect of the left forearm down into the small finger, ring finger and half of the long finger. The impression was recurrent subluxation and questionable dislocation of the left patella and rule out ulnar nerve compression of the left forearm. An electromyogram revealed slight carpal tunnel syndrome on the left side. In December 1986, private medical records from Ellen L. Parris, M.D., reported that the veteran was being evaluated for episodic numbness on his left side. The veteran reported that the first time he recalled having numbness in his left arm was in 1973 and again in 1974. He was reported to have experienced not only numbness and, at times, paresthesias of the left arm, but also numbness and tingling on the left side of his face and left leg. He was reported to have had chronic problems with his left knee. The examiner reported that, given the veteran's history and his present neurological examination, the veteran had a very good history for complicated migraine. The examiner reported that she did not find any suggestion that the veteran's base in service had anything to do with the development of his problems. On VA examination in January 1987, the veteran's right knee was reported to be totally unremarkable. The veteran was diagnosed, in part, with healed fracture of the left proximal radius, with restricted pronation and small olecranon spur; no arthritis of the left wrist or right knee; and very mild carpal tunnel syndrome by EMG on the left hand. In January 1987, a VA radiology report of the left elbow revealed an impression of old pin tract sites and cortical irregularity compatible with a healed fracture of the proximal radius. A VA radiology report of the knees revealed an impression of no fracture or significant joint abnormality of either knee. In September 1988, Marvin C. Vice, D.O., the veteran was reported to complain of bilateral knee pain. He was reported to have had persistent pain and swelling of the right knee for the last year and a half. The veteran reported that his right knee would dislocate. The impression was bilateral subluxating and dislocating patellas with chondromalacia. On VA examination in July 1989, the veteran was reported to complain that both his left and right knees popped out, with the left knee more of a problem than the right knee. He was also reported to complain of numbness and loss of range of motion of the left arm. The veteran was diagnosed with status post injury of the left knee with subsequent surgeries and minimal degenerative changes of the left knee. The evidence submitted since the August 1989 decision includes private medical records from Miami Valley Hospital, reflecting treatment from April 1990 to July 1991; private medical records from St. Joseph's Hospital, reflecting treatment from November 1991 to May 1994; an September 1995 VA joints examination; VA treatment records, reflecting treatment from July 1986 to July 1998; testimony from an October 1996 hearing at the RO; private medical records from St. Elizabeth Hospital Medical Center, reflecting treatment from December 1983 to March 1986; private medical records from Sacred Heart-St. Mary's Hospital, reflecting treatment from June 1986 to May 1988; private medical records from Northland Orthopedic Association, reflecting treatment from October 1986 to January 1988; private medical records from Wassau Hospital, reflecting treatment in May 1987; private medical records from Lafayette Home Hospital, reflecting treatment from January 1985 to February 1986; private medical records from Rhinelander Clinic, reflecting treatment from June 1986 to May 1988; a January 1999 VA joints examination; November 1999 VA examinations; and lay statements by the veteran. In May 1990, private medical records from Miami Valley Hospital reported that the veteran complained of left knee pain and numbness and tingling in the left arm and part of the right arm. He was assessed with chondromalacia of the patella and dysesthesia of the left arm and possible carpal tunnel syndrome. An x-ray study of the knees revealed some minimal lateral subluxation of the right knee and a considerably reduced lateral patellar angle. In May 1994, an x-ray study from St. Joseph's Hospital revealed an impression of no acute bony fracture of the left forearm. In June 1995, a VA outpatient treatment record assessed the veteran with severe degenerative joint disease of the knees, with the left being worse. In August 1995, a VA outpatient treatment record reported that the veteran had numbness, tingling and pain of the left arm. He was assessed with ankylosis and degenerative joint disease of the left radius, left ulnar-median nerve compression at the elbow fracture site and left carpal tunnel syndrome. On a VA joints examination in September 1995, the veteran was reported to complain that his knees were hurt while in service and that he had daily knee pain and instability. His right knee was reported to have full range of motion with no tenderness. He was diagnosed, in part, with history of surgery on the left knee times three. In February 1996, a VA radiology report of the knees revealed an impression of degenerative changes of the knees, left greater than right, which were unchanged since May 1995. In July 1996, a VA radiology report revealed an impression of the right knee to be within normal limits. In July 1996, a VA outpatient treatment record diagnosed the veteran with patellofemoral chondrosis, left greater than right. In August 1996, a VA radiology report of the right knee revealed an impression of significant movement of the patella with an abnormal superior location. The right knee was reported to show relatively normal alignment of the patellofemoral joint, some post-traumatic or post-surgical fragments of bone inferior to the patella, a knee joint that was in normal alignment and no acute fractures. During a hearing at the RO in October 1996, the veteran reported that service medical records had shown him to have bilateral chondromalacia and degenerative joint disease. He reported that his left knee was worse than his right knee. He reported that he had been treated for both knees since leaving service and that he had been given braces for both knees. He reported that he had fractured his left arm prior to service but that he began to have numbness in his left arm about a year and a half after entering service. He reported that he had surgery on his left arm while in service and that he first noticed the inability to rotate the arm after his first surgery in service. He indicated that he had an increase in left arm disability while in service. In February 1997, a VA outpatient treatment record reported that x-ray studies showed degenerative joint disease of the left elbow. In April 1998, a VA outpatient treatment record reported that the veteran had past medical history of left radial ulnar fracture and status post osteotomy in the 1970's, with subsequent repeat surgeries in 1975 and 1978. The veteran was assessed with decreased active range of motion and strength of the left hand. Received in June 1998 were private medical records from Sacred Heart St. Mary's Hospital, reflecting treatment from June 1986 to May 1988. In October 1987, the veteran was reported to have injured his right leg while moving a washing machine. The impression was acute contusion of the right patella. On a VA joints examination in January 1999, the veteran was reported to complain that he had no supination in his left upper extremity, weakness of grip and decreased sensation in the left arm. He was reported to have undergone carpal tunnel release in February 1998 and the veteran indicated that he had improved sensory motor function in his hand, although he had pain. The veteran was also reported to complain of popping in his left elbow and swelling of the right knee. There was reported to be no history of trauma to the right knee. The veteran reported that he had been favoring his right knee due to his left knee injury, which was a dislocation that had been sustained in service. A January 1998 x-ray study of the right knee was reported to show mild medial joint line narrowing and no signs of degenerative disease. X-ray studies of the forearm were reported to show postoperative changes of the proximal radius with mild angulation and mild to moderate degenerative changes around the elbow with multiple osteophytes. The veteran was diagnosed with right knee pain with no ligamentous instability, with very mild radiographic signs of degeneration and left upper extremity pain and weakness, status post right radial osteotomy approximately 24 years before. The examiner reported that it was as likely as not that the veteran's current left arm numbness was a symptom of the underlying disorder as it was due to his service-related surgery. The veteran was reported to indicate that he had decreased range of motion immediately following surgery, although the examiner reported that a review of the veteran's claims file revealed no specific records relating to the first surgery. There was reported not to have been a documented preoperative range of motion, especially of supination and pronation, although it was unlikely that the radial osteotomy had caused a decrease in the veteran's ability to supinate his forearm. The veteran was reported to have markedly improved motor sensory function following carpal tunnel release in the past year. A lot of his residuals were reported to have possibly been due to carpal tunnel syndrome, and not to the residuals of surgery around his left elbow. A current radiograph was reported to reveal degenerative changes around the proximal radial ulnar joint and ulnar humerale joint, and the veteran's decrease in range of motion was due to osteophyte formation and degeneration of the proximal radial ulnar joints than it was to postoperative changes from the radial osteotomy. The examiner reported that it was unlikely that the veteran's right knee disability was due to his service-connected left knee disability and that, at the present time, his right knee disability would be described as very mild at best. There was reported to be no ligamentous instability and very minimal signs of degeneration. On a January 1999 radiology report of the right knee, the impression was a negative right knee examination. On a January 1999 radiology report of the left forearm, the impression was stable, old, well-healed radial shaft fracture and stable degenerative changes at the elbow joint. On VA examination in November 1999, the veteran was diagnosed, in part, with status post carpal tunnel release of bilateral wrists and status post open reduction/internal fixation of fracture of the left elbow. On a November 1999 VA joints examination, the veteran reported that he thought that his right knee hurt him because of overcompensation due to his left knee condition. He was reported to have had constant pain in the knees for several years. The right knee was reported to be tender above the lateral joint line at the edge of the patella. The veteran was diagnosed, in part, with insufficient evidence to warrant a diagnosis of any acute or chronic disorder, or residuals thereof, of the right knee. II. Analysis A. New and Material Evidence When a claim has been disallowed by the RO, it may not thereafter be reopened unless new and material evidence is submitted. 38 U.S.C.A. §§ 5108, 7105 (West 1991); 38 C.F.R. § 3.104(a) (1999). The Court has indicated that the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The last disallowance of record is considered to be the last decision that finally denied the claim, whether it was denied on a new and material basis or on the merits. Evans v. Brown, 9 Vet. App. 273 (1996). In this case, the last final decision of record was August 1989 for both issues. The Board notes that the applicable regulation requires that new and material evidence is evidence which has not been previously submitted to agency decision makers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant and which, by itself, or in connection with evidence previously assembled, is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a) (1999); Hodge v. West, 155 F. 3d 1356 (Fed. Cir. 1998). In order to establish service connection for a disability, there must be objective evidence that establishes that such disability either began in or was aggravated by service, or was proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.310 (1999). In addition, service connection may be granted for a chronic disease, including arthritis, if manifested to a compensable degree with one year following service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). Upon review of the record, the Board finds that, other than some duplicate medical records, the additional evidence submitted subsequent to the August 1989 decision is new. In addition, there is new evidence, particularly the January 1999 VA examination, that is relevant to the claims of service connection and instrumental in ensuring a complete evidentiary record for evaluation of the claim. See Hodge, supra. The Board finds that this new evidence, especially when taken in light of the service medical records, is so significant that it must be considered in order to fairly decide the merits of the veteran's claims. See 38 C.F.R. § 3.156(a) (1999); Hodge, supra. Consequently, the new evidence is material. Thus, because new and material evidence has been submitted, the veteran's claims of service connection are reopened. Further, the Board notes that in Elkins v. West, 12 Vet. App. 209 (1999), the Court held that the process for reopening claims under the Federal Circuit's holding in Hodge, consists of three steps: the Secretary must first determine whether new and material evidence has been presented under 38 C.F.R. § 3.156(a); second, if new and material evidence has been presented, immediately upon reopening the Secretary must determine whether, based upon all the evidence and presuming its credibility, the claim as reopened is well-grounded pursuant to 38 U.S.C.A. § 5107(a); and third, if the claim is well-grounded, the Secretary may evaluate the merits after ensuring the duty to assist under 38 U.S.C.A. § 5107(b) has been fulfilled. The Court has stated that when the Board addresses in its decision a question that was not addressed by the RO, the Board must considered whether the claimant has been given adequate notice of the need to submit evidence or argument on that question and an opportunity to submit such evidence and argument. If not, it must be considered if the veteran has been prejudiced thereby. Bernard v. Brown, 4 Vet. App. 384, 393 (1993). In this case, the RO has considered the veteran's service connection claims on the merits; thus, there is no prejudice. As noted, in Elkins, the Court held that the process for reopening claims under the Federal Circuit's holding in Hodge, consists of three steps. First, the Secretary must first determine whether new and material evidence has been presented under 38 C.F.R. § 3.156(a). The Board has determined that new and material evidence has in fact been presented as to both service connection issues. Therefore, the second and third steps need to be undertaken. B. Well-Groundedness of Claim of Service Connection for a Right Knee Disorder The threshold question which the Board must address is whether the appellant has presented a well-grounded claim. A well-grounded claim is one which is plausible. If he has not, the claim must fail and there is no further duty to assist in the development of the claim. 38 U.S.C.A. § 5107 (West 1991); Murphy v. Derwinski, 1 Vet. App. 78 (1990). This requirement has been reaffirmed by the United States Court of Appeals for the Federal Circuit, in its decision in Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). That decision upheld the earlier decision of the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter "the Court") which made clear that it would be error for the Board to proceed to the merits of a claim which is not well grounded. Epps v. Brown, 9 Vet. App. 341 (1996). The United States Supreme Court declined to review that case. Epps v. West, 118 S. Ct. 2348 (1998). The veteran has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that his claim is well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). The Court, in Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996), outlined a three prong test which established whether a claim is well-grounded. The Court stated that in order for a claim to be well-grounded, there must be competent evidence of a current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). The Court has also stated that a claim must be accompanied by supporting evidence; an allegation is not enough. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). A claim is not well- grounded where a claimant has not submitted any evidence of symptomatology of a chronic disease within the presumptive period, continuity of symptomatology after service, or other evidence supporting direct service connection. Harvey v. Principi, 3 Vet. App. 343 (1992). In addition, the Court has also stated that when it is contended that a service-connected disability caused a new disability, competent medical evidence of a causal relationship between the two disabilities must be submitted to establish a well-grounded claim. Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). In addition, secondary service connection may be shown on the basis of aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). Evidentiary assertions by the veteran must be accepted as true for the purposes of determining whether a claim is well- grounded, except where the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). The Board notes, however, that inasmuch as the veteran is offering his own medical opinion and diagnoses, the record does not indicate that he has any professional medical expertise. See Bostain v. West, 11 Vet. App. 124, 127 (1998) ("lay testimony . . . is not competent to establish, and therefore not probative of, a medical nexus"); Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (1998). See also Espiritu v. Derwinski, 2 Vet. App. 492 (1992); Moray v. Brown, 5 Vet. App. 211 (1993); Grottveit v. Brown, 5 Vet. App. 91 (1993). Further, although the veteran asserts that his right knee disability had its onset during service or is related to his left knee disability, these assertions do not make the claim well-grounded if there is no competent medical evidence of record of a nexus between any disability in service and his alleged current disability. See Savage v. Gober, 10 Vet. App. 489 (1997); Heuer v. Brown, 7 Vet. App. at 387 (1995) (lay evidence of continuity of symptomatology does not satisfy the requirement of competent medical evidence showing a nexus between the current condition and service). As such, the Board will review the record to assess whether all three of the criteria of Caluza are met and the veteran's assertions are supported by the evidence of record. The service medical records show that, in December 1981, the veteran was reported to have progressive knee pain. He was reported to complain of bilateral chondromalacia of the patella and degenerative arthritis of both knees. However, x-ray studies of both knees revealed a normal examination. In March 1982, the veteran was reported to have a history of recurrent bilateral knee pain, and surgery on the left knee for chondromalacia patella. He was also reported to have a history of degenerative arthritis of both knees, left greater than right. A provisional diagnosis was chondromalacia patella and degenerative arthritis of the left knee. An x- ray study was reported to reveal degenerative changes and the veteran was assessed with left chondromalacia patella. Thus, while the veteran was noted to have a history of degenerative arthritis of the right knee in service, he was never reported to show x-ray evidence of arthritis of the right knee or to have an objective diagnosis of a right knee disorder. In fact, on VA examination in January 1987, the veteran's right knee was reported to be totally unremarkable and he was diagnosed with no arthritis of the right knee. A radiology report demonstrated an impression of no fracture or significant joint abnormality of either knee. Thereafter, the veteran was seen for complaints of right knee pain and subluxating and dislocating patella with chondromalacia. He was diagnosed as having degenerative joint disease and patellofemoral chondrosis; however, conflicting medical records also showed no degenerative disease. On a recent VA examination in January 1999, the veteran was diagnosed with right knee pain with no ligamentous instability and very mild radiographic signs of degeneration. The Board notes that pain alone is not a disability for the purpose of establishing entitlement to compensation benefits. See Sanchez-Benitez v. West, No. 97-1948 (U.S. Vet. App. Dec. 29, 1999). In addition, on VA examination in January 1999, the examiner reported it was unlikely that the veteran's right knee disability, which was described as being very mild at best, was due to his service-connected left knee disability. In sum, there is no medical evidence showing that there is any relationship whatsoever between service and any right knee disability nor is there competent medical evidence showing a diagnosis of arthritis of the right knee within one year of service discharge. Thus, as there is no competent medical evidence establishing a nexus between any post- service right knee disability and service, all of the criteria of Caluza have not been met. Likewise, there is no competent medical evidence of record showing that any post- service right knee disability is related to the veteran's left knee disability. As such, the claim for service connection for a right knee disability to include arthritis is not well-grounded. Since the veteran's claim is not well-grounded, he cannot invoke the VA's duty to assist in the development of the claim under 38 U.S.C.A. § 5107(a) (West 1991). Grivois v. Brown, 6 Vet. App. 136 (1994). The VA, however, may be obligated under 38 U.S.C.A. § 5103(a) to advise a veteran of evidence needed to complete his application. This obligation depends upon the particular facts of the case and the extent to which the Secretary of VA has advised the veteran of the evidence necessary to be submitted with a VA benefits claim. Robinette v. Brown, 8 Vet. App. 69 (1995). The Board finds that a remand is not required in this case. The veteran has not put VA on notice that competent evidence exists that supports his claim. The Board also notes that, in light of the veteran's current diagnoses and, as discussed hereinabove, the examiner adequately addressed the issues as put forward to him per the April 1998 remand to the RO. See Stegall v. West, 11 Vet. App. 268 (1998). Consequently, the RO has met its burden under 38 U.S.C.A. § 5103(a) by informing the veteran of the evidence necessary to complete his application for benefits. By this decision, the Board is informing the veteran of the evidence necessary to make his claim well grounded. C. Well Groundedness of Claim of Service Connection for a Left Arm and Hand Disorder The veteran contends, in essence, that he currently has a left arm and hand disorder due to disease or injury incurred in or aggravated by service. On VA examination in January 1999, the veteran was reported to complain of no supination in the left upper extremity, weakness of grip and decreased sensation of the left arm. X- ray studies of the left forearm were reported to show postoperative changes of the proximal radius with mild angulation and mild to moderate degenerative changes around the elbow with multiple osteophytes. The examiner reported that it was at least as likely as not that the veteran's current left arm numbness was a symptom of the underlying disorder as it was due to his service-related surgery. The Board finds that, in light of the veteran's left arm fracture prior to service and his treatment as demonstrated in the service medical records, the veteran's claim is plausible and capable of substantiation and, thus, well- grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1999). D. Service Connection for a Left Arm and Hand Disorder Although the veteran's claim of service connection for a left arm and hand disorder is well-grounded, the establishment of a plausible claim does not dispose of the issue in this case. The Board now must review the claim on its merits, account for the evidence which it finds to be persuasive and unpersuasive and provide reasoned analysis for rejecting evidence submitted by or on behalf of the claimant. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991 & Supp. 1999). The law provides that a veteran is presumed in sound condition except for defects noted when examined and accepted for service. Clear and unmistakable evidence that the disability existed prior to service will rebut the presumption. 38 U.S.C.A. § 1111 (West 1991). The veteran is shown to have had a fracture of the left radius prior to his entry to service. The service medical records show that, on entrance examination in September 1971, the veteran's upper extremities were reported to be clinically normal. He was noted to have had a previous left arm fracture. In September 1973, the veteran was reported to have had several episodes of numbness in the distal left upper extremity over the previous one and a half years. Such episodes were not reported to have occurred prior to service. It was noted at that time, that there was possible nerve entrapment. Thereafter, sensory complaints were repeatedly noted. Information was gleaned that the veteran had a malunion of the left radius prior to service. In light of the foregoing, the Board finds that although residual disability of the left arm was not noted upon entrance, it is clear from the ensuing records that the veteran retained residual impairment of the left arm due to his preservice fracture/malunion when he entered the service as shown on his multiple service medical records. Thus, the Board finds that there is clear and unmistakable evidence sufficient to rebut the presumption of soundness. Clear and unmistakable evidence is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. 3.306(b) (1999). The service medical records show that in January 1975, the veteran was reported to have sustained a malunion following a fracture of the left radius five years before and that he had marked limitation of supination of the arm, limited to only about 10 degrees. The veteran was reported to have underwent an osteotomy of the radius with compression plating. In November 1976, the veteran was reported to have had an open osteotomy that had gone on to a nonunion in spite of three months of plaster immobilization. He was reported to have had healing of the radius with persistent forearm pain and limitation of supination, with no supination beyond neutral position. On VA examination in January 1999, the veteran was reported to continue to complain of decreased sensation in the left arm. As noted hereinabove, the examiner reported that it was as likely as not that the veteran's current left arm numbness was a symptom of the underlying disorder and was due to his service-related surgery. The examiner also reported that the veteran had indicated that he had had a decreased range of motion of the left arm following surgery. The examiner reported that a review of the veteran's claims file had revealed no documented preoperative range of motion, especially of supination and pronation, and that it was unlikely that the veteran's radial osteotomy had caused a decrease in the veteran's ability to supinate his forearm. However, the service medical records show that, in January 1975, the veteran was reported to have sustained a malunion following a fracture of the left radius five years before and that he had marked limitation of supination of the arm, limited to only about 10 degrees. The veteran was reported to have underwent an osteotomy of the radius with compression plating. Comparatively, in November 1976, the veteran was reported to have had an open osteotomy that had gone on to a nonunion in spite of three months of plaster immobilization. He was reported to have had healing of the radius with persistent forearm pain and limitation of supination, with no supination beyond neutral position. Thus, contrary to the opinion of the examiner on VA examination in January 1999, the veteran's supination was shown to have decreased in service from about 10 degrees in January 1975 to a neutral position in November 1976. In addition, the veteran's left arm disorder had been described, in January 1975, as only a malunion, but, in November 1976, it was described as nonunion. Furthermore, on VA examination in January 1983, the veteran was reported to have no supination and he was diagnosed with postoperative residuals of injury of the left forearm. An x- ray study revealed, in part, that osteotomy defects were seen. Thus, the veteran's osteotomy of the left arm in service was shown to be manifested by symptomatology following his discharge from service that had not been present prior to his entry into service. Also, on VA examination in January 1999, the examiner reported that a lot of the veteran's left arm residuals had been possibly due to carpal tunnel syndrome, and not to the residuals of surgery around his left elbow. Thus, in effect, the examiner appeared to imply that it was possible that the veteran's current residuals were, in fact, due to his left elbow surgery. The Board notes that the veteran need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. Therefore, when a veteran seeks benefits and the evidence is in relative equipoise, the law dictates that the benefit of the doubt be extended to her. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). The evidence of record demonstrates that the veteran's left arm fracture which existed prior to service was aggravated in service, as shown by his decrease in supination, the presence of osteotomy defects shortly after service, and the acknowledgment of the examiner on VA examination in January 1999 that it was as likely as not that the veteran's current left arm numbness was due to his service-related surgery. There is no clear and unmistakable evidence demonstrating otherwise to rebut a presumption of aggravation. See 38 C.F.R. §§ 3.304, 3.306 (1999). In the Board's opinion, the evidence of record is in relative equipoise with respect to the veteran's claim of service connection for a left arm and hand disorder in that it is shown, as likely as not, that his currently demonstrated left arm and hand disorder was aggravated in service. Thus, by extending the benefit of the doubt to the veteran, the Board concludes that service connection for a left arm and hand disorder is warranted. See 38 C.F.R. § 3.303 (1999). ORDER As new and material evidence has been submitted to reopen the claim of service connection for a right knee disorder, to include arthritis, the claim is reopened. As new and material evidence has been submitted to reopen the claim of service connection for a left arm and hand disorder, the claim is reopened. Evidence of a well-grounded claim of service connection for a right knee disorder, to include arthritis, has not been submitted. Service connection for a left arm and hand disorder is granted. J. CONNOLLY JEVTICH Acting Member, Board of Veterans' Appeals