Citation Nr: 1306980 Decision Date: 02/28/13 Archive Date: 03/01/13 DOCKET NO. 08-34 486 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for low back disability. 2. Entitlement to service connection for a right elbow disability. 3. Entitlement to service connection for a left knee disability. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Higgs, Counsel INTRODUCTION The Veteran had active service from June 2000 to February 2007. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in March 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Service connection for left knee, low back and right elbow disability was originally denied in a rating decision dated in April 2007. New and material evidence, indicating chronic post-service disability of the right elbow and left knee, was received within the one-year appeal period following notice of the April 2007 RO rating decision. The required readjudication of the claims for service connection for right elbow and left knee disability was accomplished by the March 2008 RO rating decision on appeal. See 38 C.F.R. § 3.156(b) (new and material evidence-pending claim). In July 2010, the Board reopened the Veteran's claim for service connection for a low back disorder based on receipt of new and material evidence (see 38 C.F.R. 3.156(a)), and remanded the claims for service connection for a low back disorder, a right elbow disorder, and a left knee disorder to the RO for further development and adjudication. The claims were again remanded for further development and adjudication in May 2012. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. The Veteran has low back disability, variously diagnosed during the pendency of his claim as degenerative joint disease, arthritis, spondylosis, and enthesopathy; symptoms of this disorder were noted during service, he has described symptoms from active service forward, and there is medical nexus evidence linking the disorder to active service. 2. The Veteran has right elbow disability, variously diagnosed during the pendency of his claim as a right elbow sprain, tendonitis, and enthesopathy; symptoms of this disorder were noted during active service, he has described symptoms from active service forward, and there is medical nexus evidence linking the disorder to active service. 3. The Veteran has left knee disability, variously diagnosed during the pendency of his claim as a chronic left knee sprain, arthritis, and enthesopathy; symptoms of this disorder were noted during service, he has described symptoms from active service forward, and there is medical nexus evidence linking the disorder to active service. CONCLUSIONS OF LAW 1. Low back disability, variously diagnosed as degenerative joint disease, arthritis, spondylosis, and enthesopathy, was incurred in active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, (2012). 2. Right elbow disability, variously diagnosed as a right elbow sprain, tendonitis, and enthesopathy, was incurred in active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 3. Left knee disability, variously diagnosed as a chronic left knee sprain, arthritis, and enthesopathy, was incurred in active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform 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. 38 C.F.R. § 3.159(b)(1). March 2007 and July 2010 VCAA letters explained the evidence necessary to substantiate the claims for service connection. These letters also informed the Veteran of his and VA's respective duties for obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, the March 2007 and July 2010 VCAA notice letters explained how a disability rating is determined for a service-connected disorder and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the U.S. Court of Appeals for Veterans Claims held, in part, that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. Here, the Board finds that any defect with respect to the timing of the VCAA notice requirement was harmless error. Although VCAA notice was not completed prior to the initial adjudication, the claims have been readjudicated thereafter, most recently in a supplemental statement of the case dated in February 2012. The appellant has been provided with every opportunity to submit evidence and argument in support of his claims and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of his claims. VA's duty to notify in this matter has been met. With regard to the duty to assist, the claims file contains service treatment records, reports of VA post-service treatment, reports of private treatment, and reports of VA examinations. See 38 U.S.C.A. § 5103A(a)-(d). With respect to the VA examinations provided, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As the matters addressed in this decision will be resolved in favor of the Veteran, however, there is no prejudice arising to the Veteran in foregoing discussion of whether the VA examinations of record are adequate. Similarly, any deficiency in compliance with Board remands of record is no more than harmless, nonprejudicial error. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Veteran's right to remand compliance, unless there is a showing of nonprejudicial error). Based on the foregoing, the Board finds that all relevant facts have been sufficiently developed in this appeal and no further development is required. At the Veteran's March 2010 hearing, the undersigned advised the Veteran that if he could submit evidence of post-service disability of the low back, right elbow, and left knee that this would be of benefit to his claims for service connection. The undersigned left the record open for 30 days so that the Veteran could submit evidence of current disability in support of his claim, which the Veteran did do. These actions at the hearing supplemented the VCAA notice and assistance described above and were in compliance with the duties of the undersigned in his role as a VA adjudicator holding a hearing. Law and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A Veteran is presumed to be in sound condition when examined and accepted into the service except for defects or disorders noted when examined and accepted for service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). Generally, in order to prevail on the merits on the issue of service connection, there must be evidence of current disability; evidence of in-service incurrence or aggravation of a disease or injury; and evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004) The requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even in cases where the disability resolves prior to the Secretary's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321-323 (2007). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Certain chronic disabilities, to include arthritis, are presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). In the present case, as will be discussed further below, the diagnoses or other indications of arthritis of the right elbow, low back and left knee during service and within one year after his discharge from service may legitimately be questioned. Accordingly, a presumption of service connection for arthritis of the right elbow, low back or left knee is not warranted pursuant to the provisions of 38 C.F.R. §§ 3.307 and 3.309(a). However, for such chronic diseases as specifically listed at 38 C.F.R. 3.309(a), including arthritis, service connection may also be established by chronicity and continuity of symptomatology. See 38 C.F.R. § 3.303(b); Walker v. Shinseki, No. 10-2634, 2011 WL 2020827 (Vet. App. May 25, 2011). Specifically, 38 C.F.R. § 3.303(b) (Chronicity and continuity) provides that with chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Merits of the Claims At the Veteran's May 2000 service enlistment examination, clinical evolution of upper extremities, lower extremities, spine, and other musculoskeletal areas was normal. He indicated he had no history of swollen or painful joints; broken bones; arthritis, rheumatism, or bursitis; bone, joint, or other deformity; lameness; painful or "trick" shoulder or elbow; or recurrent back pain. Because the Veteran was examined as sound with respect to the right elbow, low back, and left knee upon entry into service, he is presumed to have been in sound condition with respect to these claimed disabilities at entrance into service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). In January 2001 the Veteran began to be monitored for having been treated with Isoniazid, a medication for treating tuberculosis. At such a treatment session in March 2001 he was diagnosed as having knee and ankle pain, for which he was receiving Naproxsyn. He was seen for unspecified joint problems in August 2001, diagnosed as unspecified arthralgia. In September 2001 he was again noted to have joint pain. Service treatment records indicate that the Veteran was seen for left and right wrist and right elbow pain in December 2002. The diagnoses were tendonitis of the left and right wrists and continued right elbow pain. Service records of treatment in January 2003 indicate that the Veteran was seen for dorsal wrist tendonitis and right elbow pain. He was seen in the occupational therapy department at an Army Medical Center for treatment. At occupational therapy in October 2003, examination of the Veteran's upper extremities was normal, except for weakness of the right hand and tenderness on palpation of the lateral epicondyle of the right elbow. The diagnosis was joint pain, localized in the right elbow. In January 2004 the Veteran was seen at an Army Medical Center for right elbow and wrist pain. Pain was worse with using a computer mouse, typing, or lifting. He had recently received an injection for pain relief. The diagnoses were tendonitis and enthesopathy. Several records of in-service treatment in the years 2005 and 2006 include on a problem list the following conditions: chronic pain syndrome; tendonitis and enthesopathy; joint pain, localized in the wrist; lateral epicondylitis (tennis elbow); joint pain, localized in the elbow; and tendonitis. Service treatment records show that in July 2005 the Veteran was seen for neck, right hand and low back pain. An August 2005 service treatment record indicates that the Veteran had multiple joint pain, including in the right elbow, and low back pain that was suspected to be due to musculoskeletal strain. A January 2006 X-ray of the cervical spine was positive for mild bony encroachment on the right at C5-C6 intervertebral foramen. (The Veteran has been granted service connection for cervical spine degenerative disc disease.) Also in January 2006 X-rays of the right elbow were indicated to be normal. There was found to be no evidence of joint effusion or fracture. The Veteran was diagnosed as having polyarticular arthritis. In February 2006, the Veteran was seen for suspected fibromyalgia. On review of symptoms he was found to have fatigue, mild depression, difficulty sleeping, and muscle and joint aches. The final diagnosis was fibromyalgia. Also in February 2006 the Veteran was diagnosed as having probably rheumatoid arthritis. An ANA test was noted to have been positive. March 2006 records of in-service treatment indicate a primary care physician's impression of polyarticular arthritis involving the wrists, ankles, right elbow and left knee. An isolated ANA test was noted to be positive. The Veteran was referred to a rheumatologist. An April 2006 report of medical history includes positive responses for painful shoulder, elbow or writs; arthritis, rheumatism or bursitis; recurrent back pain or any back problems; swollen or painful joints; and knee trouble. April 2006 records of in-service treatment include a diagnosis of polyarthralgia of the wrist, knee and ankle. On imaging a focal hot uptake at the left knee was interpreted as "tibial tuberosity, rule out enthesopathy." At a rheumatology work-up in April 2006 ANA screening was noted to be positive. At a service department periodical physical examination in May 2006 the Veteran was noted to have multiple joint pains, including pain in the neck, right shoulder, right elbow, wrists, left knee, ankles, and back. ANA testing was noted to have been positive at one hospital but negative at a second hospital. Treatment was noted to be ongoing. At another section of the examination an impression of osteoarthritis vs. rheumatoid arthritis is indicated, with the Veteran being currently under the evaluation of a rheumatologist. In June 2006 the Veteran was seen for chronic joint pains, mostly in the ankles bilaterally, left knee, right shoulder, left wrist, and the right side of the neck. He was noted to have gastrointestinal symptoms due to chronic use of nonsteroidal anti-inflammatory medications. The assessment was polyarticular arthritis. At a service discharge examination in November 2006, the Veteran provided positive answers with respect to whether he had now or had ever experienced a painful shoulder, elbow, or wrist; arthritis, rheumatism, or bursitis; recurrent back pain or any back problem; swollen or painful joints; knee trouble; and bone, joint, or other deformity. Corresponding clinician's impressions included epicondylitis, retropatellar pain syndrome, and lumbago. Thus, for each of the claimed conditions in this matter, symptoms and diagnoses were noted at the Veteran's service discharge examination. As noted, the Veteran was discharged from active service in February 2007. In summary, the service treatment records indicate that the Veteran was observed and treated extensively for joint pains, including of the back, right elbow and left knee. The tentative diagnoses included arthritis, enthesopathy, fibromyalgia, and polyarthralgia. The matter of diagnosis of the cause of the Veteran's complaints of joint pain was clearly a medically complex and difficult matter that remained unresolved at the time of the Veteran's discharge from service in February 2007. Further, this is a matter where arthritis was diagnosed during service, but where the diagnoses cold be legitimately questioned. See 38 C.F.R. § 3.303(b). But service connection for arthritis may be established by a showing of a current diagnosis of arthritis and continuity of symptomatology. Id. At a VA examination in January 2008, the Veteran complained of neck problems, shoulder problems, elbow problems, bilateral wrist problems, back problems, bilateral knee problems and bilateral ankle problems. This was within one year of the Veteran's discharge from service. At the January 2008 examination, the Veteran described elbow joint pains, which he stated started during his combat training. He stated that his arms were twisted and that he had pains in the elbow joints after the training. He indicated that he used pain medications occasionally. He stated that the right elbow swells up at times. He denied any locking, popping sensation or dislocation. He did not use any elbow braces. He indicated he had undergone no surgery of the elbows and that the elbow pain was usually aggravated with typing or constant repetitive motion of the upper extremities. He described only mild pains that did not affect his usual daily activities or his job. Additionally at the VA examination in January 2008, the Veteran indicated that he had injured both knees by running during physical training during active service. He stated he was given pain medications and profiled many times due to his knee condition. He was not using any knee braces. He indicated that he was using Motrin occasionally. He had undergone no surgery to the knees. On examination of the left knee at the VA examination in January 2008, there was no swelling or tenderness. Anterior drawer sign, Lachman's, and McMurray's were negative. The VA January 2008 examiner related that a December 2007 VA X-ray of the left knee showed no evidence of arthritis of the knees, and that December 2007 VA X-rays of the right elbow showed no evidence of arthritis. The January 2008 examination report states toward the end of the report that he Veteran indicated he had no complaints with respect to his low back, though at an earlier section of the report it states that he did indicate problems with his back. Medical nexus opinions were not provided in the January 2008 VA examination report. At VA treatment in June 2008, the Veteran sought treatment for pain of the neck and back. A November 2008 bone density study of the Veteran's lumbar spine and hip was indicated to be within normal limits. The study was conducted by reason of a history of the Veteran losing height. A June 2009 VA primary care note includes diagnoses of degenerative joint disease and osteopenia, but without reference to the joints affected. August 2009 and March 2010 VA treatment records include a diagnosis of degenerative joint disease of the low back. At a Board hearing in March 2010, the Veteran stated that he injured both arms, including his right elbow, in combat training. He indicated that he still had pains in both arms. He noted that X-rays of the arms had been negative. Also, at the Board hearing in March 2010, the Veteran indicated that he hurt his back a little during training. He indicated he could feel problems with his back, what he believed to be problems with disc alignment, but that nothing showed up on X-rays. He indicated that he could hear clicking sounds when he tried to "push the bone inside the place." (The Veteran's first language is not English, but rather is Korean.) Further, at the March 2010 Board hearing, the Veteran indicated that his ankles and knees would hurt in the morning when he first woke up, and that he thought that this may be a result of his running for the purpose of physical training while in the Army. At a VA examination in December 2010, the Veteran was diagnosed as having arthritis of the low back, demonstrated by December 2010 X-rays, and most likely related to active service; a chronic sprain of the right elbow, most likely related to active service; and a chronic sprain of the left knee, most likely related to active service. The opinion is based on an accurate history of the Veteran's in-service complaints, examination of the Veteran, and current diagnoses. It is a competent medical opinion of significant probative value. In a February 2011 addendum, the December 2010 VA examiner stated that she found the Veteran to be not credible based on her later review of the claims file, and that therefore she did not feel that the Veteran's claimed right elbow, left knee, and low back problems were related to service. The Board cannot ascertain the examiner's basis for summarily dismissing the Veteran's credibility, however; certainly the service treatment records are replete with treatment work-ups for right elbow, left knee, and low back complaints, as indicated by the Veteran. Thus, the Board finds that the December 2010 positive medical nexus opinions of the VA examiner are of a greater probative value than the February 2011 opinions by which the same examiner revised her opinions as to medical nexus. At a November 2011 VA examination, the examiner diagnosed the Veteran as having multiple joint pains (polyarthralgia) most likely due to enthesopathy from doing regular stretching exercises (yoga) for many years while in service and after service causing physical trauma and musculoskeletal strain on muscle and tendons around his joints. The examiner interpreted the evidence of record and the results of physical examination of the Veteran as ruling out a diagnosis of rheumatoid arthritis. This analysis does have some support in the service treatment records, to include results of a heat uptake study of the Veteran's left knee in April 2006, and corresponding diagnoses of enthesopathy. The Board further notes that incidents of stretching are documented in the service treatment records, though this was for treatment for low back and cervical spine disability, as part of a program of physical therapy. The examiner's opinions are based on accurate facts and sound reasoning, and are therefore of significant probative value. At a VA examination in June 2012, the Veteran was noted to have spondylosis of the lumbar spine at L4-5 as shown by X-ray; the Board notes that the examiner seems to have overlooked earlier X-rays that showed arthritis at L2-3. The examiner found the Veteran's arthritis of the low back to have been most likely due to "normal wear and tear" but not likely due to service. It is not clear why such normal wear and tear of the low back could not be construed as having occurred during active service, particularly in light of the Veteran's documented complaints of low back pain during service and at discharge from service. The Board further notes that this examiner did not acknowledge the extensive and complex history reflected in the Veteran's service treatment records and did not take a meaningful history from the Veteran. The June 2012 examiner overlooked the complaints of back pain, right elbow pain, and left knee pain in service during the Veteran's more than six-year period of active service. This same examiner found essentially no disability of the elbow, and arthritis of the left knee, as demonstrated by X-ray. The examiner asserted that because the Veteran had an essentially normal examination of the elbow on the day of examination, that the Veteran's right elbow symptoms were not related to service. The conclusion reached does not follow logically from the premises; the examiner's reasoning is therefore of very limited probative value. Similarly, the VA examiner's other medical opinions were very briefly reasoned and provided without reference to supporting evidence, thereby limiting their probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The examiner further opined that the Veteran, although shown to have arthritis of the left knee on X-ray, had negative X-rays of the knee in the year 2007. This aspect of the Veteran's opinion is of some probative value; however, it does not acknowledge diagnoses of arthritis during service and frequently documented symptoms of left knee disability during active service. In short, the June 2012 VA examination report is of relatively low probative value, except to document that the Veteran has current arthritis of the low back and of the left knee. Based on the foregoing, it is clear that diagnosis of the Veteran's disorders of the low back, right elbow and left knee remain complex matters on which service department clinicians and VA examiners have had differing opinions; however, the Board finds the evidence at least in equipoise to show that a current diagnosis for each claimed disability is warranted, and to show that corresponding symptoms existed and were noted during active service. There are two VA examination opinions for and two VA examination opinions against each current disorder being related to active service, and the matter does not appear to be susceptible to resolution through further development. For reasons discussed above, the Board finds the December 2010 and November 2011 medical opinions supporting the claims to establish a reasonable doubt in favor of the Veteran's claim, so as to place the evidence as to each required element, including medical nexus, medical nexus at least in equipoise. See 38 C.F.R. § 3.102. As discussed, there are significant factors detracting from the probative value and weight of the February 2011 and June 2012 VA examiners' opinions against the claims. Additionally, the Board is mindful that the Veteran has current arthritis of both the left knee and low back, and that there are tentative diagnoses of arthritis of the left knee and low back in the service treatment records, so that continuity of symptomatology, as related by the Veteran and reflected in records of treatment and examination, is an additional evidentiary basis for supporting a finding of service connection for those disabilities. See 38 C.F.R. § 3.303(b). For each claimed disability, symptoms of this disorder were noted during service, and there is competent medical nexus evidence linking a currently diagnosed disorder to active service. Thus, the essential criteria for a finding of service connection are met. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Although the June 2012 VA examiner did not acknowledge the history of or symptoms of disorders other than arthritis, these were well-documented at earlier VA examinations and in VA treatment records; the requirement that a current disability be present with respect to these aspects of his claims is therefore satisfied. McClain v. Nicholson, 21 Vet. App. 319, 321-323 (2007). Moreover, the evidence weighing in support of each claim is at least in equipoise with those aspects of the evidence weighing against the claim. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the Board find that service connection is warranted for the following disabilities: (1) low back disability, variously diagnosed as degenerative joint disease, arthritis, spondylosis, and enthesopathy; (2) right elbow disability, variously diagnosed as a chronic right elbow sprain, tendonitis and enthesopathy; and (3) left knee disability, variously diagnosed as a chronic left knee sprain, arthritis, and enthesopathy. ORDER Entitlement to service connection for low back disability, variously diagnosed as degenerative joint disease, arthritis, spondylosis, and enthesopathy, is granted. Entitlement to service connection for right elbow disability, variously diagnosed as a chronic right elbow sprain, tendonitis, and enthesopathy, is granted. Entitlement to service connection for left knee disability, variously diagnosed as a chronic left knee sprain, arthritis, and enthesopathy, is granted. ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs