Citation Nr: 0208066 Decision Date: 07/18/02 Archive Date: 07/19/02 DOCKET NO. 99-16 626 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania THE ISSUE Entitlement to an increased rating for a left knee disability, currently assigned a 20 percent evaluation. ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION The veteran had active service from November 1982 to October 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an RO decision of February 1999 which denied an increase in a 20 percent rating for a left knee disability. In December 2000, the case was remanded to the RO for additional development. FINDING OF FACT The veteran's left knee disability is manifested by full extension, flexion from 120 to 145 degrees, and no arthritis or instability. CONCLUSION OF LAW The criteria for an evaluation in excess of 20 percent for a left knee disability have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Codes 5257, 5260, 5261 (2001). REASONS AND BASES FOR FINDING AND CONCLUSION I. Background The veteran had active service from November 1982 to October 1986. Service medical records show the veteran's complaints of left knee pain, and a finding of chondromalacia patella. Subsequent to service, left knee diagnoses have included tendinitis and strain. In March 1988, the RO granted service connection and a 0 percent rating for left knee strain. In December 1997, the RO increased the left knee disability rating to 10 percent. In a decision in July 1998, the Board granted a 20 percent rating for the veteran's left knee disability. In October 1998, the veteran filed a claim for an increased evaluation for his left knee disability, stating that he had severe chronic pain in the knee. Records of the veteran's treatment within the University of Pennsylvania Health System show that in September 1998, he complained of "water on the left knee." He stated that the pain started two weeks ago, while he was weightlifting. The left knee had minimal to undetectable swelling, no crepitus, no tenderness to palpation, good stability, and no warmth or erythema. The assessment was patellar tendonitis. In October 1998, he complained that he still had left knee pain, and that the knee gave way sometimes. On examination, there was no laxity or effusion. There was some tenderness. The assessment was chondromalacia. In November 1998, the veteran was evaluated by a private orthopedic surgeon, M. Ellen, M.D. The veteran reported a several week flare up of anterior knee pain. He noted increasing pains if he ran for long periods of time on hard surfaces. He said ascending and descending stairs increased pain. He was able to maintain a seated position without pain or stiffness. He said he did not have swelling these days. On examination, range of motion was from 5 to 10 degrees of recurvatum to 145 degrees of flexion. He had mild delays in patellar seating, and a slight increase in medial-lateral patellar play. Palpation revealed tenderness about the medial patellar facets and medial retinacular structures. He had no patellar tendon or joint line tenderness. There was no evidence of ligamentous instability. He did have congenital hyper-ligamentous laxity throughout his upper and lower extremities. He was able to achieve a squat position The impression was patellofemoral pain syndrome. Alteration in his weight lifting program, to avoid irritating the knee, and stretching were advised. On a December 1998 VA examination, the veteran reported that he could ambulate without restriction, but after 10 to 15 minutes, he started to experience pain, which progressed the longer that he walked. He could go up and down steps without real dysfunction. Examination demonstrated mild tenderness over the left knee joint, without swelling. Range of motion was from 0 degrees of extension to 120 degrees of flexion. There was no instability. The diagnostic impression was chondromalacia, prone to exacerbations of knee pain, with no evidence of incoordination or fatigability. The doctor noted that it was impossible to predict the amount of restriction when he had flare-ups. Outpatient treatment records from the University of Pennsylvania Health System include a complaint of left knee pain, unable to work, noted in February 1999. In January 2000, he complained of knee pain for a week. It was noted that he worked at the mint, and had an active lifestyle. He complained of pain with ambulation. He was doing knee exercises, but they were not helping. He did not have erythema, swelling, warmth, or tenderness, and drawer signs were negative. He did have crepitus, pain with flexion and extension, and minimal swelling. Light duty was recommended. In December 2000, he was noted to have a normal squat. In August 2001, he was evaluated for his knees, especially the left knee. He complained of pain in the whole front to the knee when walking up stairs and on level ground. Examination disclosed a negative Lachman's and anterior drawer. There was no medial or lateral cruciate ligament laxity. There was minimal crepitus in the left patella with reproduction of pain with patellar percussion. There was no effusion or joint line pain. The assessment was patellofemoral syndrome. He was provided exercises for hamstring stretching. VA outpatient treatment records dated from January 2000 to July 2001 show complaints of knee pain. The veteran also said he had swelling on occasion. He was noted to be a student, and also had a job working at the mint, operating a machine that cut blank coins, noted to be less physically demanding. A VA examination in September 2001 noted there was no history of fatigability or incoordination in the left knee. He was able to participate in sporting activities, including basketball, with pain. He stated he wore a knee brace intermittently. On examination, there was normal contour of the left knee, with range of motion from 0 to 125 degrees with no instability of the left knee joint. There was no evidence of fatigability or incoordination, but he was prone to exacerbations. It was not possible to predict the future degree of dysfunction. The diagnostic impression was tendinitis of the left knee. X-rays were normal. II. Analysis The file shows that through correspondence, the rating decision, the statement of the case, supplemental statements of the case, and a previous remand, the veteran has been notified of the evidence necessary to substantiate his claim for an increase in a 20 percent rating for a left knee disability. He has been afforded VA examinations, and identified relevant medical records have been obtained. The Board is satisfied that the notice and duty to assist provisions of the law have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West Supp. 2001); 66 Fed. Reg. 45,620, 45,630 (Aug. 29, 2001) (to be codified at 38 C.F.R. § 3.159). Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. Separate rating codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. A knee impairment with recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Limitation of leg flexion is rated 0 percent when limited to 60 degrees, 10 percent when limited to 45 degrees, 20 percent when limited to 30 degrees, and 30 percent when limited to 15 degrees. 38 C.F.R. § 4.71a, Code 5260. Limitation of extension of a leg is rated 0 percent when limited to 5 degrees, 10 percent when limited to 10 degrees, 20 percent when limited to 15 degrees, 30 percent when limited to 20 degrees, 40 percent when limited to 30 degrees, and 50 percent when limited to 45 degrees. 38 C.F.R. § 4.71a, Code 5261. Recent examination and treatment records show no instability of the left knee; there is no recurrent subluxation or lateral instability as required for even a compensable rating under Code 5257. There is no left knee arthritis shown by X- rays, and thus no basis for rating arthritis under Code 5003 or Code 5010. As to limitation of motion, one recent examination noted left knee recurvatum of 5 to 10 degrees, meaning the knee could be hyperextended to this extent. A 10 percent rating may be granted for traumatic acquired genu recurvatum, with weakness and insecurity in weight-bearing objectively demonstrated. 38 C.F.R. § 4.71a, Code 5263. The evidence as a whole shows the left knee disability does not meet these criteria. Most of the recent medical records simply show full extension of the knee, and such would be rated 0 percent under Code 5261. The recent medical records show left knee flexion ranging from 120 degrees to 145; that is, slightly limited to full flexion. If strictly rated under Code 5260, such would be rated 0 percent. Even taking into the account the effect of pain on motion, it is clear that left knee flexion does not result in disability exceeding the current 20 percent rating. While the veteran has subjective complaints of left knee pain, the degree of his complaints is not supported by objective pathology. 38 C.F.R. §§ 4.40, 4.45, DeLuca v. Brown, 8 Vet.App. 202 (1995). Separate ratings may be assigned for arthritis with limitation of motion of a knee (Diagnostic Codes 5003-5010) and for instability of a knee (Diagnostic Code 5257). VAOPGCPREC 23-97 and 9-98. However, the veteran does not have either arthritis or instability. Accordingly, separate evaluations are not warranted. In weight of the credible evidence demonstrates that the veteran's left knee disability is no more than 20 percent disabling. The preponderance of the evidence is against the claim for an increased rating for the left knee disability; thus, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). ORDER An increased rating for a left knee disability is denied. L. W. TOBIN Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.