Citation Nr: 0217048 Decision Date: 11/25/02 Archive Date: 12/04/02 DOCKET NO. 91-35 834 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana THE ISSUES 1. Entitlement to an increase in a 30 percent rating for a right knee disability. 2. Entitlement to an increase in a 20 percent rating for a left knee disability. REPRESENTATION Appellant represented by: Mark R. Lippman, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant and a friend ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The veteran had active service from July 1959 to January 1962. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a June 1990 RO rating decision which denied an increased (compensable) rating for the veteran's service-connected tendinitis of the infrapatellar ligaments of both knees. In November 1991, the Board remanded the appeal to the RO for further development to include consideration of an intertwined claim of service connection for other disorders of the knees. A February 1992 RO decision granted an increased rating of 10 percent for the veteran's service-connected patellar tendinitis of the right knee. A September 1992 RO decision re-characterized the veteran's service-connected left knee disability as residuals of arthroscopic surgery of the left knee with a history of tendinitis of the infrapatellar ligaments and granted a temporary total convalescent rating from August 1992 to October 1992, followed by a 10 percent rating. A June 1993 RO decision denied secondary service connection for a total right knee replacement (arthroplasty). In July 1995, the Board again remanded the appeal to the RO to obtain a medical opinion on the etiology of the total right knee replacement. In a June 1997 decision, the Board denied an increase in a 10 percent rating for the veteran's service-connected patellar tendinitis of the right knee; denied an increase in a 10 percent rating for his service-connected residuals of arthroscopic surgery of the left knee with a history of tendinitis of the infrapatellar ligaments; and denied secondary service connection for a total right knee replacement. The veteran then appealed to the United States Court of Appeals for Veterans Claims (Court). In April 1998, the parties (the veteran and the VA Secretary) filed a joint motion with the Court, requesting that the Board decision be vacated and the case remanded for further action. By an April 1998 order, the Court granted the motion, and the case was thereafter returned to the Board. In September 1998, the Board remanded the appeal to the RO for further development. Thereafter, in September 1998, the RO informed the veteran that he was never given notice of a November 1970 rating decision which denied service connection for residuals of a medial and lateral meniscectomy of the right knee. The RO forwarded the veteran a copy of the November 1970 rating decision and informed him of his appellate rights. In October 1998, the veteran's representative filed a notice of disagreement with respect to the November 1970 rating decision. The veteran and his representative were sent a statement of the case on this issue in October 1998. The veteran submitted a related substantive appeal in October 1998 and the Board determined that the claim for service connection for residuals of a medial and lateral meniscectomy of the right knee was properly before the Board. The veteran requested a Board hearing but withdrew such hearing request in May 2000. In February 2001, the Board again remanded this appeal to the RO for further development. In June 2002, the RO granted additional service connection for residuals of a right knee total arthroplasty with osteophyte formation and re-characterized the veteran's service-connected right knee disability as patellar tendonitis of the right knee with total knee replacement (arthroplasty). A 10 percent rating was assigned effective June 8, 1970. A temporary total rating based on right knee replacement was granted from December 28, 1992 to February 1, 1994, followed by a 30 percent rating. As to the veteran's service-connected left knee disability, the RO increased the rating from 10 percent to 20 percent. As the RO has granted the veteran's claims for service connection for residuals of a medial and lateral meniscectomy of the right knee and for a total right knee replacement, such issues are no longer before the Board. Therefore, the Board will address the issues as indicated on the title page of this decision. FINDINGS OF FACT 1. The veteran's service-connected right knee disability (total knee replacement with history of patellar tendonitis) was previously assigned a temporary total rating for one year after implantation of the prosthesis, and the condition is now symptomatic and productive of some functional impairment, but is not manifested by severe painful motion or weakness of the affected extremity, ankylosis of the knee, extension of the leg limited to more than 20 degrees (motion was from 10 to 100 degrees on last examination), or the equivalent of nonunion with loose motion of the tibia and fibula. 2. The veteran's service-connected left knee disability (residuals of arthroscopic surgery with history of tendinitis of the infrapatellar ligaments) is manifested by osteoarthritis described as not significant, limitation of motion no worse than flexion limited to 30 degrees and extension limited to 15 degrees (motion was from 5 to 125 degrees on last examination), and no current instability. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for a right knee disability have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Diagnostic Codes 5055, 5256, 5261, 5262 (2001). 2. The criteria for a rating 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, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran served on active duty in the Marine Corps from 1959 to 1962. His service medical records indicate that he was treated for knee complaints, and among the diagnoses were patellar tendinitis and psychogenic musculoskeletal reaction. In January 1962, the veteran filed a claim for service connection for knee problems. The veteran underwent a VA general medical examination in March 1962. The diagnosis was tendinitis of both infrapatellar ligaments. In April 1962, the RO granted service connection for tendinitis of the infrapatellar ligaments of both knees. A noncompensable rating was assigned. Private physician statements dated in 1962 and 1963 show that the veteran continued to receive treatment for knee complaints. In June 1970, the veteran filed a claim for an increased rating for a right knee disability. Private treatment records from 1970 reflect that the veteran was treated for a right knee disability. A September 1970 statement from L. H. Smith, M.D., reported that he treated the veteran in February 1970 after he had injured his right knee the previous night while playing basketball. The injury resulted in tears of the medial and lateral menisci which were removed in an operation in April 1970. The diagnosis was torn menisci (lateral and medial) of the right knee. The veteran underwent a VA orthopedic examination in October 1970. The diagnosis was residuals of medial and lateral meniscectomies of the right knee. Private treatment records dated from 1975 to 1990 indicate that the veteran received treatment for disorders including right and left knee complaints. In June 1990, the veteran filed a claim for an increased rating for his bilateral knee disability. A June 1990 RO decision denied an increased rating for the veteran's bilateral knee disability. At a December 1990 hearing, the veteran testified primarily with regard to his right knee symptoms. He stated that his left knee hurt once in a while. Private treatment records dated from July 1990 to January 1991 refer to treatment for other disorders. The veteran underwent a VA orthopedic examination in February 1991. The examination was essentially limited to the right knee. It was noted that he complained of dull pain 85 percent of the time when working and standing. He also stated that he would trip easily and that he did not have locking of the knee, but that it would give out. The examiner reported that there were two incisions of 8-cm and 9-cm on each side of the right knee with no swelling. Both sides of the knees were noted to be symmetrical. The examiner reported that range of motion of the right knee was from 0 degrees to 100 degrees with 0 to 135 degrees for the left knee. The examiner noted that there was some tenderness over the right knee at both sides and that the stability was good. The diagnosis was sequela of a right knee injury. Private treatment records dated from 1991 reflect treatment for disorders other than knee problems. The veteran underwent an additional VA orthopedic examination in January 1992. It was noted that he mainly complained of right knee pain and that he denied left knee pain. He described pain in the anterior aspect of the right knee and in the medial lateral aspects of the knee. The veteran reported that he had problems with standing, walking and bending of his knee and that he had to physically use his hands to bend his right knee. He complained of a marked increase in pain over the previous two or three years. The examiner reported that there was no effusion of the bilateral knees. The right quad mechanism had marked atrophy compared to the left knee. The examiner noted that the left knee range of motion was 0 to 135 degrees with right knee range of motion from 5 to 110 degrees with pain on motion. The examiner indicated that on palpation of the knee there was marked tenderness over the insertion of the patella tubercle. It was reported that the veteran also had tenderness at the medial aspect of the knee with possible band extending from the femoral condyle to the patella which was markedly tender. The examiner stated that the Lackman's test was negative, bilaterally, as were the drawer signs. The examiner reported that the veteran did appear to have some lateral laxity on the right knee with no laxity, medially or laterally, on the left knee. The impression was right knee patellar tendinitis, degenerative joint disease of the right knee, medical and lateral compartments, quadriceps atrophy, and possible plaque on the medial aspect of the left knee. A February 1992 RO decision increased the rating for the veteran's service-connected tendinitis of the infrapatellar ligaments of the right knee from noncompensable (0 percent) to 10 percent. A noncompensable (0 percent) rating was continued for the veteran's service-connected tendinitis of the infrapatellar ligaments of the left knee. Private treatment records dated from 1992 show that the veteran was treated for his knee disabilities. A June 1992 treatment entry from Orthopaedics Northeast, Inc., indicated that the veteran was seen for right knee pain. An August 1992 entry noted that the veteran was seen for complaints of severe pain in the left knee after he bumped it at work. It was reported that he had had no problems with the left knee before the injury, and that most of his problems had been related to his arthritis of the right knee. Another August 1992 entry indicated that the veteran underwent a lateral meniscectomy of the left knee. A September 1992 RO decision re-characterized the veteran's service-connected left knee disability as residuals of arthroscopic surgery of the left knee with a history of tendinitis of the infrapatellar ligaments and granted a temporary total convalescent rating from August 1992 to October 1992, followed by a 10 percent rating. Private medical records dated from 1992 and 1993 refer to continued treatment. A December 1992 report from Parkview Memorial Hospital noted that the veteran was admitted with severe degenerative changes of the right knee. He underwent a right total knee arthroplasty and progressed well with physical therapy following his surgery. The impression was degenerative arthritis, right knee, for total knee arthroplasty. The veteran underwent a VA orthopedic examination in January 1993. He complained of some knee pain for the about the past year although he indicated that his left knee was doing fairly well at the present time. It was noted that the veteran underwent a right total knee arthroplasty in December 1992 and that he was presently on crutches. The veteran reported that his right knee was quite painful and that he was unhappy with the range of motion. The examiner reported, as to the veteran's right knee, that there was a well healed mid-line scar. It was noted that there was no effusion present, but that the knee was warm to palpation. The examiner indicated that range of motion was from 30 degrees to 60 degrees and that the veteran's knee was stable to varus and valgus stress. As to the left knee, the examiner indicated that the range of motion was from 10 to 120 degrees. The examiner reported that there was no effusion present and that the veteran was stable to varus and valgus stress. The examiner stated that the veteran had a negative drawer and a negative Lachman. It was reported that X-rays of the left knee, dated in January 1992, revealed a small calcification, but were otherwise normal with minimal degenerative joint disease. The impression was left knee, doing fairly well, asymptomatic, and right knee, status post total knee arthroplasty, approximately one month earlier. The veteran testified at a hearing at the RO in March 1993. He stated that his right knee pain was better following the recent surgery. He reported he had constant pain and trouble sleeping at night but reported there had not been any instability in either knee but that he did have swelling of the right knee. Private treatment records dated from February 1993 to April 1993 indicate that the veteran continued to receive treatment for his knee disabilities. A June 1993 RO decision denied secondary service connection for a total right knee replacement (arthroplasty). Private treatment records dated from July 1993 to December 1993 show continued treatment for multiple disabilities. The veteran underwent a VA orthopedic examination in September 1995. The examiner reported that the veteran had a well-healed incision on the right side. The examiner indicated that the veteran lacked 10 degrees of extension and had 92 degrees of flexion as to the right knee. The examiner also noted that there was no varus/valgus instability on the right operative knee. As to the veteran's left knee, the examiner stated that the range of motion was from 10 degrees to 130 degrees, with no instability. It was reported that the veteran complained of some tenderness and pain at the tibial insertion of the patella region. A September 1995 radiological report, as to both knees, related an impression of status post right total knee replacement since the prior study and degenerative changes of the left knee consistent with osteoarthritis. The veteran underwent an additional VA orthopedic examination in May 1996. He reported that since undergoing the total knee arthroplasty, his right knee did not bother him at all. It was noted that the veteran's only concern was decreased range of motion which was normal for a total knee arthroplasty. The examiner reported that on the right side, there was an incision consistent with the total knee arthroplasty. The examiner indicated that range of motion was from 0 to 90 degrees with no apparent instability and good muscle strength. There was no tenderness or palpation. The examiner reported that examination of the left knee revealed tenderness at the patellar tendon. Range of motion was from 0 to 115 degrees with no apparent instability and good muscular strength. The examiner reported that X-rays revealed a total knee arthroplasty on the right and what appeared to be good preserved joint space on the left. Private treatment records dated from June 1998 to September 1998 indicate that the veteran was treated for disorders including knee disabilities. A treatment entry dated in, apparently, September 1998, from Orthopaedics Northeast, Inc., noted that the veteran had retained excellent range of motion of the knees. It was noted that the veteran had good stability and no signs of any effusions. Another report from such facility dated, apparently, in September 1998 noted that examination of the right knee revealed a range of motion from 0 to 110 degrees with good medial and lateral stability. It was noted that there were no effusions. As to the left knee, the examiner indicated that there was excellent range of motion and excellent ligamentous stability. The examiner noted that there was a previous arthroscopy scar on the right knee. The veteran underwent a VA orthopedic examination in April 1999. It was noted that his main complaints were that he had never regained full range of motion of his right knee after a total knee replacement. The veteran reported that he still had pain in the right knee and that he used a cane for ambulation. He also stated that he had problems with his left knee. The examiner reported that the left knee range of motion was from 0 to 135 degrees with no hyperextension. It was noted that the veteran did have crepitus through his patellofemoral joint and that he did have patellar tendon tenderness at the insertion of his patellar tendon and just underneath the patella. The examiner also reported that the veteran had positive patellar tenderness indicating patellofemoral symptoms. The examiner further reported that the veteran medial joint line tenderness on the right side. Range of motion was 0 to 95 degrees with pain. The examiner noted that the veteran had extreme patellar tenderness on the right side, more than so than on the left. It was reported that the veteran had stable varus valgus components to his knee replacement and no signs of effusions. The examiner noted that the veteran was extremely tender along the lateral border of the patella. A March 2001 medical evaluation report from C. N. Bash, M.D., related opinions as to the etiology of some of the veteran's right knee pathology. Present symptomatology was not reported. The veteran underwent another VA orthopedic examination in March 2002. He reported that he had increasing anterior knee pain and indicated that he could only walk for one block. The veteran noted that the pain was anterior into the knee and the patellar tendon. It was noted that the veteran also had some mild intermittent swelling and associated problems with his right knee. The veteran stated that he felt that his left knee had become problematic because of his right knee. It was reported that the left knee had a similar kind of anterior knee pain at the insertion of the patellar tendon on the patella. The veteran indicated that such had been a severe problem for at least the previous five years. He reported that he had constant pain and that he had received multiple cortisone injections which offered him only a short-term benefit of approximately several days. The examiner reported that, as to the right knee, the veteran had a range of motion of 10 to 100 degrees. The examiner stated that the veteran had obvious inferior pole patellar pain at the insertion of the patellar tendon. It was noted that there was no varus/valgus instability. The examiner reported that there was no abnormal patellar "clunk" with smooth range of motion and that he had a slight amount of crepitus under the patella. It was noted that there was a mildly positive patellar grind and shrug test and that there was no obvious swelling or evidence of infection in the veteran's knee. The examiner reported that the veteran had +5/5 strength in his quadriceps, hamstrings, extensor hallucis longus, plantar flexors and dorsiflexors bilaterally. The examiner indicated that examination of the left knee showed a similar type of patellar tendonitis and that there was pain at the inferior pole of the patella and throughout the entire tendon insertion as well as the entire patellar tendon, even down to the tibial insertion. It was noted that the range of motion was from 5 to 125 degrees. The examiner indicated that there was no varus/valgus instability and that there was a negative Lachman, McMurray, and anterior/posterior drawer. There was also a negative pivot shift. The examiner stated that a review of the veteran's X-rays showed a well-implanted right total knee arthroplasty with significant joint space narrowing from polyethylene wear as well as some osteophyte formation of the back side of the patella from a non-resurfaced patella. It was noted that X-rays of the "right" knee showed no obvious deformities. As to an impression, the examiner noted that the veteran had an obvious right knee arthroplasty with the development of osteophyte formation from a non-resurfaced patella which was causing a significant amount of anterior knee pain, as well as associated patellar tendonitis. The examiner also indicated that the veteran's left knee had persistent patellar tendonitis with not significant osteoarthritis, which would preclude the veteran from any type of surgical procedure at this time. A June 2002 RO decision granted additional service connection for residuals of a right knee total arthroplasty with osteophyte formation, and re-characterized the veteran's service-connected right knee disability as total knee replacement (arthroplasty) with history of patellar tendonitis. A 10 percent rating was assigned effective June 8, 1970. A temporary total rating based on right knee replacement was granted from December 28, 1992 to February 1, 1994, followed by a 30 percent rating. As to the veteran's service-connected left knee disability, the RO increased the rating from 10 percent to 20 percent. II. Analysis Through correspondence, the rating decision, the statement of the case, the supplemental statements of the case, and the multiple Board remands, the veteran has been informed of the evidence necessary to substantiate his claims. VA examinations have been provided, and relevant medical records obtained. The Board finds that the notice and duty to assist provisions of the Veterans Claims Assistance Act of 2000, and the related VA regulation, have been satisfied. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). However, in a claim for increased rating, the most recent evidence is generally the most relevant, as the present level of disability is of primary concern. Francisco v. Brown, 7 Vet.App. 55 (1994). Prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. (The 1-year total rating commences after a 1-month convalescent rating under 38 C.F.R. § 4.30). Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrants a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5261, or 5262. The minimum rating for replacement of a knee joint is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Malunion of the tibia and fibula with marked knee disability, warrants a 30 percent rating. Nonunion, with loose motion requiring a knee brace requires a 40 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5262. 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. Ankylosis of a knee that is at a favorable angle in full extension, or in slight flexion between 0 and 10 degrees, warrants a 30 percent rating. A 40 percent rating requires ankylosis in flexion between 10 and 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Degenerative or traumatic arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joints or joint involved. When there is arthritis with at least some limitation of motion, but such limitation would be rated noncompensable under a limitation-of-motion code, a 10 percent rating may be assigned for each involved major joint. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010. Limitation of flexion of a leg to 60 degrees warrants a 0 percent rating. A 10 percent rating requires that flexion be limited to 45 degrees. A 20 percent rating requires that flexion be limited to 30 degrees. The highest available rating, 30 percent, is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of a leg to 5 degrees warrants a 0 percent rating. A 10 percent rating requires that extension be limited to 10 degrees. A 20 percent rating requires that extension be limited to 15 degrees. A 30 percent rating requires that extension be limited to 20 degrees. A 40 percent rating requires that extension be limited to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The standard range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. A. Increased Rating for a Right knee Disability The veteran underwent a total knee arthroplasty of the right knee in December 1992. The RO, pursuant to the June 2002 rating decision, granted a one-month temporary total convalescent rating and then a one-year temporary total evaluation following implantation of the prosthesis under the provisions of 38 C.F.R. §§ 4.30 and 4.71a, Diagnostic Code 5055. The temporary total rating expired at the end of January 1994. Effective in February 1994, the RO assigned a 30 percent rating for the knee replacement. The Board finds that a rating in excess of the 30 percent for the veteran's right knee is not warranted. The recent examination reports, including the March 2002 VA orthopedic examination report, show that the veteran had no varus/valgus instability of the right knee. Additionally, the March 2002 examination report noted that the range of motion of the right knee was from 10 to 100 degrees. The medical evidence does not show that the veteran's right knee disability includes severe painful motion or weakness in the affected extremity so as to warrant a 60 percent rating under Diagnostic Code 5055. There is no recent clinical evidence of instability of the prosthetic joint of the right knee or any severe weakness. The Board has considered whether more than the minimum 30 percent rating for a right knee replacement may be assigned based on an intermediate degree of residual weakness, pain, and limitation of motion, rating by analogy under Diagnostic Codes 5256, 5262, or 5262. The examinations of record, including the March 2002 examination, indicate that the veteran has some limitation of motion of the knee, but not ankylosis or complete immobility of the knee. Thus, an increased rating under Diagnostic Code 5256 is not indicated. The current 30 percent rating is the maximum rating allowed for limitation of flexion of a knee or leg (Diagnostic Code 5260), and the degree of limitation of extension reported on the most recent examination report falls short of what is required for a rating in excess of 30 percent under Diagnostic code 5261. As the recent medical evidence shows that the veteran's prosthetic right knee is stable and intact, a rating of 40 percent by analogy to nonunion of the tibia and fibular with loose motion under Diagnostic Code 5262 is not warranted. The Board also finds that in considering the effects of pain on use or during flare-ups, the range of motion reported in the recent examination and treatment records as to the veteran's right knee simply does not meet the standards for a rating of even 30 percent. 38 C.F.R. §§ 4.40, 4.45, 4,59; Deluca v. Brown, 8 Vet.App. 202 (1995). The minimum rating of 30 percent under Code 5055 for right knee replacement is more advantageous to the veteran. As the preponderance of the evidence is against the claim for an increased rating for a right knee disability, 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). B. Increased Rating for a Left Knee Disability The most recent March 2002 VA orthopedic examination report noted that range of motion of the veteran's left knee was from 5 to 125 degrees. The examiner indicated that examination of the left knee showed patellar tendonitis and that there was pain at the inferior pole of the patella and throughout the entire tendon insertion as well as the entire patellar tendon, even down to the tibial insertion. The examiner reported that there was no varus/valgus instability and that there was a negative Lachman, McMurray, and anterior/posterior drawer. As to an impression, the examiner commented that the veteran's left knee had persistent patellar tendonitis with no significant osteoarthritis. The Board observes that the veteran has been shown to have arthritis of the left although it has been described as "not significant". The Board observes that in assuming arthritis of the left knee and considering the effects of pain on use, the range of motion reported at the March 2002 examination report, as well as other recent examination and treatment records, does not meet the standards for a 20 percent under the limitation-of-motion codes (Diagnostic Codes 5260 and 5261). 38 C.F.R. §§ 4.40, 4.45, 4.59; Deluca, supra. The reported range of motion at the last examination would be rated 0 percent under the limitation-of-motion codes, although the presence of arthritis with at least some limitation of motion supports a 10 percent rating under the arthritis codes. Additionally, the recent medical evidence, including the March 2002 examination report, has shown no subluxation or instability of the left knee. Thus a compensable rating under Code 5257 is not in order. 38 C.F.R. § 4.31. A separate compensable rating for instability under Code 5257 is not warranted. See VAOPGCPREC 23-97 and 9-98. The weight of the credible evidence demonstrates that the veteran's left knee disability is not more than 20 percent disabling. As the preponderance of the evidence is against the claim for an increased rating for the left knee disability, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b);Gilbert, supra. ORDER An increased rating for a right knee disability is denied. 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.