Citation Nr: 0814944 Decision Date: 05/06/08 Archive Date: 05/12/08 DOCKET NO. 07-02 338 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for left heel pain. 2. Entitlement to service connection for residuals of a right great toe injury. 3. Entitlement to service connection for a left shoulder disability. 4. Entitlement to service connection for a left elbow disability. 5. Entitlement to an initial evaluation in excess of 10 percent for degenerative arthritis of the bilateral knees, status post right meniscectomy due to a lateral meniscus tear. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD L. J. N. Driever, Counsel INTRODUCTION The veteran had active service from June 1984 to January 2006. These claims come before the Board of Veterans' Appeals (Board) on appeal of a June 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. The veteran testified in support of these claims at a hearing held at the RO before the undersigned Veterans Law Judge in February 2008. A transcript of the hearing testimony is part of the claims file. The veteran also initiated an appeal of the RO's June 2006 assignment of an initial 10 percent evaluation for a low back disability. However, since the RO issued a statement of the case on that claim in August 2007, the veteran has not perfected his appeal by submitting a VA Form 9 or any other document that could be construed as a substantive appeal. This claim is thus not now before the Board for appellate review. FINDINGS OF FACT 1. VA provided the veteran adequate notice and assistance with regard to his claims. 2. The veteran does not have a left heel disability manifested by pain. 3. The veteran has no residuals of a right great toe injury. 4. The veteran does not currently have a left shoulder disability. 5. The veteran does not currently have a left elbow disability. 6. Degenerative arthritis of both knees is minimal, causing intermittent right knee pain during certain activities and slight limitation of motion of both knees. CONCLUSIONS OF LAW 1. Left heel pain was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 2. Residuals of a right great toe injury were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 3. A left shoulder disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 4. A left elbow disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2007). 5. The criteria for entitlement to an initial evaluation in excess of 10 percent for degenerative arthritis of the right knee, status post right meniscectomy due to a lateral meniscus tear, have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2007). 6. The criteria for entitlement to an initial separate 10 percent evaluation for degenerative arthritis of the left knee, status post right meniscectomy due to a lateral meniscus tear, have been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist On November 9, 2000, the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002), became law. Regulations implementing the VCAA were then published at 66 Fed. Reg. 45,620, 45,630-32 (August 29, 2001) and codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2007). The VCAA and its implementing regulations are applicable to this appeal. The VCAA and its implementing regulations provide, in part, that VA will notify the claimant and his representative, if any, of the information and medical or lay evidence not previously provided to the Secretary that is necessary to substantiate a claim. As part of the notice, VA is to specifically inform the claimant and his representative, if any, of which portion of the evidence the claimant is to provide and which portion of the evidence VA will attempt to obtain on the claimant's behalf. They also require VA to assist a claimant in obtaining evidence necessary to substantiate a claim, but such assistance is not required if there is no reasonable possibility that such assistance would aid in substantiating the claim. The United States Court of Appeals for Veterans Claims (Court) has mandated that VA ensure strict compliance with the provisions of the VCAA. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). In this case, VA provided the veteran adequate notice and assistance with regard to his claims such that the Board's decision to proceed in adjudicating them does not prejudice the veteran in the disposition thereof. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). A. Duty to Notify The Court has indicated that notice under the VCAA must be given prior to an initial unfavorable decision by the agency of original jurisdiction. In Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 119-20 (2004), the Court also indicated that the VCAA requires VA to provide notice, consistent with the requirements of 38 U.S.C.A. § 5103(A), 38 C.F.R. § 3.159(b), and Quartuccio, that informs the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim, (2) that VA will seek to provide, and (3) that the claimant is expected to provide. In what can be considered a fourth element of the requisite notice, the Court further held that, under 38 C.F.R. § 3.159(b), VA must request the claimant to provide any evidence in his possession that pertains to the claim. Id. at 120-21. In March 2006, the Court held that the aforementioned notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of disability; (3) a connection between service and disability; (4) degree of disability; and (5) effective date of disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006). The Court further held that notice under the VCAA must inform the claimant that, if the RO grants his service connection claim, it will then assign such an award a disability rating and an effective date. It must also explain to the veteran how it determines the appropriate rating to assign a disability. Id. at 486. In this case, the RO provided the veteran VCAA notice on his claims by letters dated December 2005, February 2006 and March 2006, the first two sent before initially deciding those claims in a rating decision dated June 2006. The timing of such notice reflects compliance with the requirements of the law as found by the Court in Pelegrini II. The content of such notice also reflects compliance with the requirements of the law as found by the Court in Pelegrini II and Dingess/Hartman. In the aforementioned notice letters, the RO acknowledged the claims being decided, notified the veteran of the evidence needed to substantiate those claims, identified the type of evidence that would best do so, informed him of VA's duty to assist, and indicated that it was developing his claims pursuant to that duty. The RO also provided the veteran all necessary information on disability ratings and effective dates, including an explanation of what is reviewed in determining a disability rating. The RO specifically indicated that it considered the nature and symptoms of the disability, the severity and duration of the symptoms and the impact the symptoms have on employment. As well, the RO identified the evidence it was responsible for securing in support of the veteran's claims. The RO noted that it would make reasonable efforts to assist the veteran in obtaining all outstanding evidence provided he identified the source(s) thereof. The RO also noted that, ultimately, it was the veteran's responsibility to ensure VA's receipt of all pertinent evidence. The RO advised the veteran to sign the enclosed forms authorizing the release of his treatment records if he wished VA to obtain such records on his behalf. The RO also advised the veteran to identify or send directly to VA all evidence he had in his possession, which pertained to his claims. B. Duty to Assist VA made reasonable efforts to identify and obtain relevant records in support of the veteran's claims. 38 U.S.C.A. § 5103A(a), (b), (c) (West 2002). Specifically, the RO secured and associated with the claims file all evidence the veteran identified as being pertinent to these claims, including service medical records and post-service treatment records. In a form and memorandum dated December 2005 and January 2006, the veteran and his representative indicated that there was no further information or evidence to present. The RO also conducted medical inquiry in support of the veteran's claims by affording the veteran VA examinations, during which VA examiners addressed the etiology and severity of the disabilities at issue in this decision. The veteran does not now claim that the reports of these examinations are inadequate to decide his claims. Under the facts of this case, "the record has been fully developed," and "it is difficult to discern what additional guidance VA could have provided to the veteran regarding what additional evidence he should submit to substantiate his claim[s]." Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004); see also Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the claimant). II. Analysis of Claims A. Claims for Service Connection The veteran claims entitlement to service connection for left heel pain, residuals of a right great toe injury and left shoulder and left elbow disabilities. Service connection may be granted for disability resulting from injury or disease incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). Subsequent manifestations of a chronic disease in service, however remote, are to be service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be presumed for arthritis if it is shown that the veteran served continuously for 90 days or more during a period of war or during peacetime after December 31, 1946, and manifested such condition to a degree of 10 percent within one year from the date of his discharge with no evidence of record establishing otherwise. 38 U.S.C.A. §§ 1101, 1112(a), 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2007). In order to prevail on the issue of service connection on the merits, there must be medical evidence of a current disability, see Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in- service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Left Heel Pain According to the veteran's written statements submitted during the course of this appeal and his hearing testimony, presented in February 2008, the veteran injured his left heel in service when he stepped on an object with his bare feet. It imbedded itself in his left foot, thereby necessitating removal, after which his foot bled, and treatment with alcohol and gauze. Allegedly, he did not report foot problems or seek left heel care after the injury, but experienced residuals of that injury, including occasional pain during certain activities. As previously indicated, the veteran served on active duty from June 1984 to January 2006. During this time period, as alleged, he did not report or seek treatment for heel complaints and no medical professional, including on separation examination, noted any left heel abnormalities. Since discharge, the veteran has received treatment for medical complaints, none involving his heels or feet, and has undergone a VA examination of his feet. During that examination, conducted in April 2006, the examiner objectively confirmed intermittent heel pain improved with shoe inserts and without sequelae, but he did not attribute the pain to any particular disability. Moreover, x-rays revealed no abnormalities indicating the presence of such a disability. Pain, alone, without a diagnosed or identifiable underlying malady or condition does not, in and of itself, constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). In this case, the veteran's assertions represent the only evidence of record establishing that he has a disability caused by the pain. These assertions may not be considered competent evidence of a nexus as the record does not reflect that the veteran possesses a recognized degree of medical knowledge to diagnose a medical condition. Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992) (holding that laypersons are not competent to offer medical opinions). Inasmuch as there is no competent medical evidence of record establishing that the veteran has a disability manifested by left heel pain, the Board concludes that left heel pain was not incurred in or aggravated by service. The claim for service connection for such pain is not in relative equipoise; therefore, the veteran may not be afforded the benefit of the doubt in the resolution thereof. Rather, as a preponderance of the evidence is against the claim, it must be denied. 2. Residuals of Right Great Toe Injury & Left Shoulder and Elbow Disabilities The veteran asserts that, in service, a serviceman dropped a metal chop block on his right great toe, causing bleeding and pain and a smashed second toenail. He also asserts that, in service, he injured his left shoulder while lifting weights and pulling up beams. He reportedly injured his left elbow when he hyperextended it during a platoon competition and again, subsequently, while lifting weights. The veteran contends that, following the left shoulder and elbow injuries, he sought treatment by medics, who diagnosed bursitis. Allegedly, after service, the veteran's right great toe did not heal properly and he continued to experience pain and throbbing of the right great toe during certain activities. According to the veteran's service medical records, during active duty from June 1984 to January 2006, he injured his left shoulder and elbow, as alleged, and sought treatment for complaints associated therewith. Examiners diagnosed a strained rotator cuff and tendonitis. The veteran also sought treatment for right great toe complaints, which an examiner attributed to onychomycosis. On separation examination, the veteran reported left shoulder and elbow symptoms and the examiner noted chronic left shoulder and elbow complaints. The examiner did not attribute these complaints to a particular disability. Since discharge, the veteran has received treatment for medical complaints, none involving his right great toe or left shoulder or elbow, and has undergone a VA examination of his feet, left shoulder and left elbow. During that examination, conducted in April 2006, the examiner noted no abnormal findings of the right great toe, left shoulder or left elbow. As well, he refrained from diagnosing any right great toe, left shoulder or left elbow disability and x-rays revealed no abnormalities indicating the presence of such disabilities. Again, the veteran's assertions, which are not competent, represent the only evidence of record establishing that he has right great toe, left shoulder and left elbow disabilities. Inasmuch as there is no competent medical evidence of record establishing that the veteran has these disabilities, the Board concludes that they were not incurred in or aggravated by service. The claims for service connection for such disabilities are not in relative equipoise; therefore, the veteran may not be afforded the benefit of the doubt in the resolution thereof. Rather, as a preponderance of the evidence is against the claims, they must be denied. B. Claim for a Higher Initial Evaluation The veteran claims entitlement to a higher initial evaluation for his bilateral knee disability. He asserts that the evaluation initially assigned this disability does not accurately reflect the severity of his bilateral knee symptomatology. Allegedly, such symptomatology includes constant right knee swelling, right knee pain during certain activities, left knee clicking, popping and occasional pain, and necessitates the intermittent use of a right knee brace and pain medication. Disability evaluations are determined by evaluating the extent to which a service-connected disability adversely affects a veteran's ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10 (2007). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7 (2007). Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). In claims for increases, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). A disability may require re-evaluation in accordance with changes in a veteran's condition. In determining the level of current impairment, it is thus essential that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The examination on which an evaluation is based must adequately portray the anatomical damage, and the functional loss, with respect to all of these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. §§ 4.40, 4.45 (2007). As regards the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: less movement than normal; more movement than normal; weakened movement; excess fatigability; incoordination, impaired ability to execute skilled movements smoothly; and pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight- bearing are related considerations. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995) (holding that VA's review of a service-connected musculoskeletal disability must include an assessment of the functional impairment caused by that disability and that, if the service-connected disability involves a joint rated based on limitation of motion, adequate consideration must be given to functional loss due to pain under 38 C.F.R. § 4.40, and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45). Painful, unstable, or maligned joints due to healed injury are entitled to at least the minimum compensable evaluation for the joint. 38 C.F.R. § 4.59 (2007). The Office of General Counsel (GC) has issued two opinions pertinent to claims of entitlement to higher initial evaluations for knee disabilities. These GC opinions reflect that a veteran who has x-ray evidence of arthritis and instability of the knee may be evaluated separately under Diagnostic Codes (DCs) 5003 and 5257 provided additional disability is shown. VAOPGCPREC 23-97 (July 1, 1997) (23- 97); VAOGCPREC 9-98 (August 14, 1998) (9-98). Additional disability is shown when a veteran meets the criteria for a noncompensable evaluation under either DC 5260 or 5261, which include flexion limited to 60 degrees or extension limited to 5 degrees, or when there is painful motion such that it adds to the actual limitation of motion shown under DC 5260 or DC 5261. 9-98 at paragraphs 1, 6. A separate evaluation may also be granted under DC 5003 and 38 C.F.R. § 4.59, when a veteran technically has full range of motion that is inhibited by pain. 9-98 at paragraphs 4, 6; see also Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). The RO has evaluated the veteran's bilateral knee disability as 10 percent disabling pursuant to Diagnostic Codes (DCs) 5010 and 5260. DC 5010 provides that arthritis due to trauma, substantiated by x-ray findings, is to be rated as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010 (2007). DC 5003 provides that degenerative arthritis established by x-ray findings is to be evaluated on the basis of limitation of motion under the appropriate DC for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate DC, an evaluation of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is assignable for x-ray evidence of involvement of arthritis of 2 or more major joints or 2 or more minor joint groups. A 20 percent evaluation is assignable for x-ray evidence of involvement of arthritis of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating episodes. 38 C.F.R. § 4.71a, DC 5003 (2007). The appropriate DCs for the specific joint involved in this case are DC 5260 and 5261. These DCs provide that a 10 percent evaluation is assignable for flexion of the leg limited to 45 degrees and extension of the leg limited to 10 degrees. A 20 percent evaluation is assignable for flexion of the leg limited to 30 degrees and extension of the leg limited to 15 degrees. 38 C.F.R. § 4.71a, DCs 5260, 5261 (2007); see also VAOGCPREC 9-2004 (Sept. 17, 2004) (holding that separate evaluations under 38 C.F.R. § 4.71a, DC 5260 (leg, limitation of flexion) and DC 5261 (leg, limitation of extension) may be assigned for disability of the same joint). Also applicable to this case are DCs 5256 and 5257. DC 5257 provides that a 10 percent evaluation is assignable for slight recurrent subluxation or lateral instability of the knee. A 20 percent evaluation is assignable for moderate recurrent subluxation or lateral instability of the knee. A 30 percent evaluation is assignable for severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, DC 5257 (2007). DC 5256 provides that an evaluation of at least 30 percent is assignable for ankylosis of the knee. 38 C.F.R. § 4.71a, DC 5256 (2007). Based on these criteria as well as the reasoning noted below, the evidence establishes that the veteran's right knee disability picture does not more nearly approximate the criteria for a higher initial evaluation under any applicable DC. This evidence also establishes that the veteran's left knee disability picture more nearly approximates the criteria for an initial separate 10 percent evaluation. During service, the veteran tore his lateral meniscus when he twisted his right knee. This tear necessitated arthroscopic surgery, after which the veteran reported various knee symptoms. On separation examination, an examiner noted chronic right knee pain. Following discharge, the veteran underwent a VA examination of his knee, during which he reported right knee weakness when playing basketball and occasional slight right knee swelling and pain. He further reported that the knee symptoms did not prevent him from working and had not required medical attention. The examiner noted right knee range of motion from 0 to 125 degrees and left knee range of motion from 0 to 132 degrees. The examiner further noted that the knee joints were not limited by pain, fatigue, weakness or lack or endurance on repetitive use. Based on x- rays, the examiner diagnosed minimal degenerative arthritis of both knees and status post right meniscectomy, intermittent right knee pain with prolonged basketball or running. In sum, degenerative arthritis of the veteran's knees is minimal, causing intermittent right knee pain during certain activities and slight limitation of motion of both knees. See 38 C.F.R. §§ 4.71, Plate II (noting normal range of motion of the knee as 0 to 140 degrees). This degree of limited motion is not compensable under DC 5260 or 5261. However, as previously indicated, under DC 5003, when limitation of motion of a specific joint in noncompensable, an evaluation of 10 percent is applicable. In this case, the veteran is already in receipt of such an evaluation for his right knee. He is also entitled to the same evaluation for his left knee. He is not entitled to initial evaluations in excess of 10 percent for either knee, however, as there is no evidence of instability or subluxation, moderate or otherwise, or ankylosis. In light of the foregoing, the Board concludes that the criteria for entitlement to an initial evaluation in excess of 10 percent for degenerative arthritis of the right knee, status post right meniscectomy due to a lateral meniscus tear, have not been met. The Board also concludes that the criteria for entitlement to an initial separate 10 percent evaluation for degenerative arthritis of the left knee, status post right meniscectomy due to a lateral meniscus tear, have been met. The Board recognizes that the rating schedule is designed to accommodate changes in condition and that the veteran may be awarded different evaluations in the future should either of his knee disability pictures change. 38 C.F.R. § 4.1. At present, however, the above noted evaluations are the most appropriate given the medical evidence of record. In reaching this decision, the Board considered the complete history of the disabilities at issue as well as the current clinical manifestations and the effect these disabilities have on the earning capacity of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. In addition, the Board considered the applicability of the benefit-of-the-doubt doctrine, but because the evidence is not in relative equipoise, the veteran may not be afforded the benefit of the doubt in the resolution of his claims for a higher initial evaluation for a right knee disability. Rather, as a preponderance of the evidence is against such claim, it must be denied. As the evidence supports the claim for an initial separate 10 percent evaluation for a left knee disability, it must be granted. ORDER Service connection for left heel pain is denied. Service connection for residuals of a right great toe injury is denied. Service connection for a left shoulder disability is denied. Service connection for a left elbow disability is denied. An initial evaluation in excess of 10 percent for degenerative arthritis of the right knee, status post right meniscectomy due to a lateral meniscus tear, is denied. An initial separate 10 percent evaluation for degenerative arthritis of the left knee, status post right meniscectomy due to a lateral meniscus tear, is granted subject to statutory and regulatory provisions governing the payment of monetary benefits. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs