Citation Nr: 1800587 Decision Date: 01/05/18 Archive Date: 01/19/18 DOCKET NO. 14-17 464 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an initial compensable rating of 10 percent for right knee arthritis prior to April 15, 2013. 2. Entitlement to an initial compensable rating of 10 percent for l knee arthritis prior to April 15, 2013. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.Lee, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Air Force from May 1991 to November 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2014 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In May 2017, the Veteran testified during a videoconference hearing before the undersigned. A transcript of the hearing is associated with the record. FINDING OF FACT The Veteran was diagnosed with bilateral knee arthritis during the course of the appeal, and there is evidence of pain with motion of the knees. CONCLUSIONS OF LAW 1. For the entire period of appeal, the criteria for the assignment of a rating of 10 percent for the right knee disability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5260-5003 (2017). 2. For the entire period of appeal, the criteria for the assignment of a rating of 10 percent for the left knee disability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5260-5003 (2017). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran was initially awarded a noncompensable rating, effective December 1, 2011. The Veteran's bilateral knee arthritis is currently rated at a 10 percent disability rating for each knee under Diagnostic Code 5260-5003, effective April 15, 2013. 38 C.F.R. §§ 4.20, 4.27 (2017). He contends he should have been awarded an initial 10 percent disability rating for each knee, effective on December 1, 2011. The Veteran clarified during his Board hearing that a 10 percent rating for each knee disability The Board finds that for the entire period on appeal, the record does demonstrate the requisite manifestations for a rating of 10 percent for each knee disability under Diagnostic Code 5260-5003. Diagnostic Code 5260 provides a zero percent rating for flexion limited to 60 degrees, 10 percent for flexion limited to 45 degrees, 20 percent for flexion limited to 30 degrees, and a maximum of 30 percent for flexion limited to 15 degrees. Id. As discussed above, arthritis is rated on the basis of limitation of motion for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint so affected. In the absence of limitation of motion, x-ray evidence of arthritis involving two or more major or minor joint groups will warrant a 10 percent rating, and two or more major or minor joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The 10 percent and 20 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 1. In October 1990, the Veteran was admitted to the hospital for right kneecap pain for the past 24 hours. Pain was specifically under the right patellar and flexor of knee. However, by observation time, the pain had discontinued. Upon examination, the right knee had no effusion, no instability, and proved negative for Lachman, Drawer, or McMurray's tests. The Veteran was diagnosed with patellofemoral pain. In various Air Force examinations from September 1985 to March 1995, the Veteran reported his lower extremities were normal. In June 2003, the Veteran complained of right knee pain after exercise, especially running, and the pain had continued for 48 hours. He reported that Motrin helped but he was unable to tolerate exercise or pulling "G's" for a year. The Veteran reported undergoing no trauma or receiving any treatment. The right knee was mildly tender to palpation at the proximate portion of the right patella tendon and the inferior pole of the patella. There was bony prominence at insertion; no effusion; and no erythema, heat, or ligament instability. The left knee was negative for meniscus signs. The physician diagnosed the Veteran with right patellar tendonitis. The Veteran was prescribed Celebrex and referred the Veteran for x-ray review by an orthopedist. In March 2004, the Veteran was evaluated by a VA orthopedic surgeon for right anterior focal knee pain at the inferior pole of patella. He reported the pain had been going on for two to three years, and was especially severe when/after he ran. He reported a lot of pain in that region, although stated there was no catching or locking; no instability; and no previous injury. The Veteran received anti-inflammatory medications and underwent physical therapy for pain. Upon examination, the Veteran had range of motion measured from zero to 140 degrees; soft tissue mass and exquisite tenderness at the inferior pole of the patellar; no medial or lateral joint line tenderness; and intact sensation. The physician diagnosed the Veteran with probable patellar tendinitis. In April 2004, the Veteran received a MRI of his right knee. He complained of soft tissue mass at the inferior pole of his patella growing in size, and how it was unresponsive to physical therapy or anti-inflammatory medication. The physician found the focal area of abnormal signal was in the proximal patellar tendon near its insertion on the patella; that there was a rounded appearance that may be responsible for the palpable abnormality; and that the entire patellar tendon was mildly thickened. The physician found degenerative changes of the menisci, although no definite tear was seen. The physician opined the Veteran had chondromalacia. In May 2004, the Veteran complained of right knee pain after running for a year, possibly because he was flat-footed. He reported that if he was not wearing shoes that had good support, he would also have lower back pain. The Veteran stated that he wore over-the-counter inserts for padding in his flight boots. In August 2010, the Veteran sought treatment for his knee pain after running a 5K race in the morning. He reported being unable to sit still after sitting down due to the pain under his left knee cap, along the medial joint line and at the top of the patella tendon. The Veteran complained of his pain occurring at rest after exercise and more recently, even without activity, and waking him up during sleep. He reported the pain was throbbing, felt stiff, and made it painful for him to drive. The Veteran also compared the pain to his right knee issues from several years ago. He rated the pain at three out of ten, minimum, and seven out of two, at worst. He also reported feeling a bump that was increasing at size at the base of the patella. The physician did not find the left knee joint to be unstable, grating, or grinding. The physician also found no swelling, induration, edema, erythema, warmth, dislocation, deformity, or patellofemoral lateral tracking. Pain was elicited by motion of the knee. Additionally, the physician found mobility, movement, motion, flexion, extension, medial translation, lateral translation, medial rotation of the tibia on the femur, and lateral rotation of the tibia on the femur, was normal. The physician concluded that the left knee patella demonstrated crepitus, the inferior pole patella was tender on palpation, and the medial joint line was tender on palpation. In August 2010, the Veteran also underwent a MRI for his left knee pain. The VA radiologist found his bone mineralization was normal; and found no evidence of acute fracture or dislocation. Joint spaces were within normal limits; and there were no destructive bony lesions or degenerative changes. Soft tissues were found to be grossly normal, and the radiologist stated it was a normal examination. Various service treatment records from March 2011 to May 2011 show the Veteran complained of his left knee aching, especially after running. He reported struggling with patella tendonitis since July 2010. Treatment included icing, orthotics use, patellar band use, taking his prescribed Celebrex, cortisone injections, and physical therapy. The physician noted that when the Veteran was not active, there were no glaring issues. In January 2011, the Veteran was seen for complaints of left knee pain for the past six months, even after taking his prescribed Celebrex. He rated the pain was three out of 10. In March 2011, the Veteran was seen at a Flight Medicine Clinic of left knee pain. Upon examination, his bilateral knees were deemed normal. The physician noted full range of motion; flexion and extension was normal; and no pain was elicited by motion of the knee. Additionally, there was no hypertension, instability, or subluxation. The Veteran also reported having a lot of activity limitation and very minimal improvement of his left knee over the past six months. On another March 2011 visit to the VA doctor, the Veteran reported running three to four days a week, for three to five miles each day. He complained of aching pain at the inferior pole of the patella and the patella tendon at the inferior pole, the day after running. He rated the pain from seven to eight out of 10, for up to 24 hours. Upon examination, the physician found the Veteran was tight in his quad tendon, and his patellar tendon was tender to palpation. The physician diagnosed him with left knee pain. In April 2011, the Veteran went to a VA physical therapist for his left knee. The VA physical therapist noted that the Veteran utilized a patellar band and orthotics, took prescribed Celebrex when flying, and iced his left knee on a nightly basis. The Veteran had to take gaps in formal physical therapy due to high temporary duty assignment (TDY) tempo to maintain flying hours. The therapist diagnosed the Veteran with left knee pain. In April 2013, the Veteran was given MRIs of both knees. The radiologist found that the left knee showed intrasubstance degeneration of the posterior horn of the medial meniscus. The radiologist found that the right knee showed tendinosis within the control deep fibers of the proximal tendon; and that there was intrasubstance degeneration within the posterior horn of the lateral meniscus. Upon reviewing weight-bearing x-rays, the radiologist stated that each knee showed normal appearance of the bony structures, with the exception of an osteophyte at the lower pole of the right patella. The radiologist opined that there were normal left knee x-rays; and osteophyte at the attachment of the patellar ligament to the lower pole of the right patella, which may reflect a chronic tendonitis. He opined that there was no evidence of significant osteoarthritis. In October 2013, the Veteran was afforded a VA examination of both knees. Here, the VA examiner measured right and left knee flexion as 140 degrees or greater, with no objective pain on motion; and right and left knee extension measured as having no limitation of extension or objective pain on motion. During a range of motion test, the Veteran was able to perform repetitive-use testing with three repetitions. There was no degree of hyperextension for either knee. The VA examiner observed functional loss due to pain on movement for each knee. He rated the Veteran has five out of five on bilateral knee flexion and extension strength tests. Additionally, it was noted that the Veteran had pain or tenderness on palpation on both patellar tendons. There was normal joint stability on tests for both knees, as well as meniscal tears on both knees. The VA examiner diagnosed the Veteran with degenerative or traumatic arthritis of both knees, bilateral patellar tendinosis, and meniscal degeneration. He opined there was no patellar subluxation. In May 2017, the Veteran testified at a videoconference hearing. He testified that as of the initial effective date of December 1, 2011, the Veteran was still receiving treatment for knee pain including continuous physical therapy for his left knee. He testified that he was unable to run for his Air Force physical therapy test due to his knee pain. He also testified that during a VA physical in July 2011, the physician did not perform a range of motion test, although noting that there was no pain, fatigue, or weakness after repetitive use. The Veteran testified that during VA examinations of his knees, he was receiving treatment and taking Celebrex, and one VA physician opined that the treatments and medication had positive effects "to the point where the pain and inflammation in that knee was reduced during the VA examination to where it wasn't painful on range of motion and also it wasn't being used very much." See May 2017 Hearing Transcript, p. 6. The Veteran testified that he was still taking 400 milligrams of Celebrex daily as an anti-inflammatory for his knee pain. In sum, the evidence shows that the Veteran was diagnosed with left and right knee disabilities during the course of this appeal. The Board observes that a 10 percent rating for bilateral knee disabilities under Diagnostic Code 5260-5003 contemplates the effects of any complaints of pain, fatigue, swelling, weakness, or lack of endurance. The Veteran consistently reported aching pain and swelling for both knees, especially after physical activity such as running. He stated that he had to ice nightly, and use a patella band and orthotics to alleviate the pain. The Veteran's medical records show a consistent prescription of Celebrex for knee pain relief, as well as cortisone injections as part of his physical therapy treatment. Significantly, the VA physicians repeatedly stated that there was pain or tenderness on palpation for both patellar tendons, pain on motion of the knee, and bilateral degeneration of menisci. Additionally, during treatment notes where range of motion was found to be normal, the Board notes that the Veteran was actively receiving treatment for his knees, and taking medication. Thus, the preponderance of the evidence is for the award of a 10 percent disability rating for the bilateral knee disabilities for the entire period of appeal. Accordingly, the benefit of the doubt is for application on the matter of nexus, and the increased rating is established. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. ORDER An initial rating of 10 percent for the Veteran's right knee arthritis prior to April 15, 2013, is granted. An initial rating of 10 percent for the Veteran's left knee arthritis prior to April 15, 2013, is granted. ____________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs