Citation Nr: 1815280 Decision Date: 03/12/18 Archive Date: 03/19/18 DOCKET NO. 14-28 941A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to a rating in excess of 30 percent for residual recurrent dislocation of the right patella with chondromalacia. 2. Entitlement to a rating in excess of 30 percent for residual recurrent dislocation of the left patella with chondromalacia. 3. Entitlement to compensation under the provisions of 38 U.S.C. § 1151 (2012) for additional heart disability caused by VA treatment from December 12, 2002 to December 14, 2002 at the Phoenix VA Medical Center (VAMC). WITNESSES AT HEARING ON APPEAL Appellant and his spouse. ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from June 1960 to July 1963. This case comes before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. In February, 2017, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at the RO. A transcript of the hearing is of record. This case was previously before the Board in May 2017. At that time, the Board denied a claim for entitlement to service connection for a cervical spine disability and remanded the claims for increased ratings for the knees and entitlement to compensation under 38 U.S.C. § 1151 for additional development. The increased rating and 38 U.S.C. § 1151 claims have now returned to the Board for further appellate action. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. The Veteran's right and left knee disabilities manifest impairment of the tibia and fibula with a marked knee disability without nonunion, loose motion, or requiring a brace. 2. The Veteran's right knee disability manifests arthritis with limitation of flexion to 120 degrees and extension limited to 5 degrees without instability, symptomatic removal of the semilunar cartilage, ankyloses, or frequent episodes of locking, joint pain, and effusion. 3. The Veteran's left knee disability manifests arthritis with limitation of flexion to 120 degrees and extension limited to 2 degrees without instability, symptomatic removal of the semilunar cartilage, ankyloses, or frequent episodes of locking, joint pain, and effusion. 4. The Veteran did not incur a heart disability in addition to a myocardial infarction (MI) due to VA treatment from December 12, 2002 to December 14, 2002 at the Phoenix VAMC. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for recurrent dislocation of the right patella with chondromalacia are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7. 4.10, 4.71a, Diagnostic Codes 5262 (2017). 2. The criteria for a rating in excess of 30 percent for recurrent dislocation of the right patella with chondromalacia are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7. 4.10, 4.71a, Diagnostic Code 5262. 3. The criteria for a separate 10 percent rating, but not higher, for right knee painful motion with arthritis (previously characterized as limitation of extension of the right knee) throughout the claims period are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5256-5261. 4. The criteria for a separate 10 percent rating, but not higher, for left knee painful motion with arthritis throughout the claims period are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5256-5261. 5. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for additional heart disability incurred due to VA treatment from December 12, 2002 to December 14, 2002 at the Phoenix VAMC are not met. 38 U.S.C. § 1151; 38 C.F.R. §§ 3.361, 17.32. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Increased Ratings Knees The Veteran contends that higher ratings are warranted for his service-connected right and left knee disabilities. Service connection for recurrent dislocations of the right and left patella as a residual of knee surgery was granted in an October 1963 rating decision. Initial 20 percent evaluations were assigned effective July 4, 1963. The service-connected disabilities were later recharacterized as residual recurrent dislocations of the patella with chondromalacia in a March 2002 rating decision. This rating decision also assigned separate increased 30 percent evaluations for each knee effective September 19, 2001. The January 2012 rating decision on appeal continued the current 30 percent ratings. In an October 2017 rating decision, a separate noncompensable (0 percent) evaluation for right knee limitation of extension was awarded effective August 16, 2017. Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's right and left knee disabilities are currently rated as 30 percent disabling under Diagnostic Code 5262 for impairment of the tibia and fibula with a marked knee disability. Under this diagnostic code, a maximum 40 percent evaluation is possible with nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. The Veteran has not manifested any evidence of nonunion or loose motion of the tibia and/or fibula during the claims period, and he has not required the use of a brace for either leg. The August 2017 VA examiner noted the presence of some tibial and/or fibular impairment, but specified that such impairment was limited to a past history of recurrent patellar dislocation with no current evidence of this condition. VA and private treatment records are similarly negative for any current evidence of loose motion or nonunion and these symptoms were also not identified upon VA examination in May 2011. As there is no evidence of the criteria necessary for a maximum 40 percent evaluation, the Board finds that an increased rating is not warranted under Diagnostic Code 5262. The Board will now address whether higher and/or separate ratings are warranted for the Veteran's knee disability based on limitation of motion. The right knee is in receipt of a noncompensable rating for limitation of extension; the left knee is not rated for any limitation of motion. After review of the evidence, the Board finds that separate 10 percent ratings are warranted for each knee under Diagnostic Code 5003 based on noncompensable limitation of motion. Under Diagnostic Code 5003 for rating degenerative arthritis, a 10 percent evaluation is assigned when limitation of motion is noncompensable for a major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Limitation of flexion of a leg warrants a 10 percent evaluation if flexion is limited to 45 degrees and a 20 percent evaluation is assigned if flexion is limited to 30 degrees. Flexion that is limited to 15 degrees is evaluated as 30 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of a leg warrants a 10 percent evaluation when it is limited to 10 degrees and a 20 percent evaluation when it is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Regarding the right knee, the Veteran is currently in receipt of a 0 percent (noncompensable) evaluation for limitation of extension under Diagnostic Code 5003-5261 from August 16, 2017. The Board finds that a 10 percent rating for painful noncompensable limitation of extension is appropriate throughout the entire period. Limitation of motion of the right knee was most restricted at VA examinations when flexion was limited to 120 degrees (measured at the May 2011 examination) and extension was limited to 5 degrees (at the August 2017 examination) with pain noted on weight-bearing. Arthritis of the right knee is also confirmed by radiographs performed throughout the claims period. Extension limited to 5 degrees is contemplated by a 0 percent rating under Diagnostic Code 5261; however, as this degree of limited motion is noncompensable and accompanied by pain, the Board finds that an increased 10 percent rating is appropriate under Diagnostic Code 5003. The Board also finds that the 10 percent rating under Diagnostic Code 5003 is appropriate throughout the claims period. Although the Veteran did not manifest pain during range of motion testing at the May 2011 VA examination, he testified that he experienced pain with motion in his right knee and he is competent to describe the symptoms he experiences. Therefore, a 10 percent rating for noncompensable limitation of motion is warranted for the right knee throughout the claims period. Similarly, the Board finds that a separate 10 percent rating is warranted for painful noncompensable limitation of motion of the left knee throughout the entire claims period. Movement of the left knee was most restricted at the August 2017 VA examination when flexion was limited to 120 degrees and extension was limited to 2 degrees. This degree of limitation of flexion and extension are both noncompensable under Diagnostic Codes 5260 and 5261. As the record also establishes arthritis confirmed by X-ray findings and competent complaints of painful left knee motion, a separate 10 percent rating for noncompensable painful motion is appropriate for the left knee under Diagnostic Code 5003. The Board has also considered whether more than one rating is warranted for noncompensable limitation of motion for the right or left knees. Although the Veteran has manifested noncompensable limitation of extension and flexion in both knees, separate ratings are not appropriate. VA's General Counsel has held that separate ratings are available for limitation of flexion and limitation of extension, but specified that these separate ratings were only appropriate under Diagnostic Codes 5260 and 5261 and were not applicable to a rating assigned under Diagnostic Code 5003. VAOPGCPREC 9-2004, 69 Fed. Reg. 59,990 (2004). Additionally, Diagnostic 5003 provides that a single 10 percent rating is warranted for each "major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003." As the Veteran is already in receipt of a 10 percent rating for painful motion under Diagnostic Code 5003 for each knee (the applicable major joint), additional ratings under this same code are prohibited. The Board also notes that ratings based on compensable limitation of motion are not warranted. As noted above, range of motion of the knees was most restricted at the May 2011 and August 2017 VA examinations when the right knee manifested flexion to 120 degrees and extension limited to 5 degrees. The left knee manifested flexion to 120 degrees and extension limited to 2 degrees. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. In applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. Even with consideration of all applicable functional factors, it is clear that compensable ratings are not warranted for either knee under Diagnostic Code 5260 or 5261. The Veteran did not experience pain during range of motion testing at the May 2011 VA examination and did not experience pain until the endpoint of testing during the August 2017 examination. There was also no additional loss of motion with repetitive testing at either examination. The August 2017 VA examiner noted that the Veteran experienced impairment to kneeling and running associated with the service-connected disability, but the Board finds this impairment is contemplated by the currently assigned ratings for each knee. The VA examiner also observed that the Veteran kept an active lifestyle with consistent walking at work and carrying animal feed bags weighing approximately 50 pounds (lbs.). Thus, even with consideration of functional factors, the Board finds that the Veteran's limitation of motion and functional impairment does not most nearly approximate the criteria for compensable ratings under Diagnostic Codes 5260 and 5261. The Board also finds that separate evaluations are not appropriate for either knee under Diagnostic Code 5257 for instability. See VAOPGCPREC 23-97 (a claimant who has arthritis and instability of the knee may be rated separately under diagnostic Codes 5003 and 5257). Recurrent subluxation or lateral instability warrants a 10 percent evaluation if it is slight, a 20 percent evaluation if it is moderate, or a 30 percent evaluation if it is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. In this case, there is no medical evidence of knee instability or subluxation at any time during the claims period. The May 2011 and August 2017 VA examiners both found that the Veteran's knees were stable and did not demonstrate recurrent subluxation upon physical examination. Although the Veteran testified in February 2017 that he often fell because of symptoms due to his knees, the Veteran also stated that his physicians associated his falls to neurological impairment in his legs. Private and VA treatment records establish that the Veteran's leg weakness and neurological impairment are related to a lumbar spine disability and are not due to the service-connected knee conditions. For example, in May 2014, the Veteran's physical therapist found that his leg weakness and decreased sensation was likely due to lumbar stenosis. As the Veteran does not manifest recurrent subluxation or lateral instability of the right or left knees, separate ratings are not warranted under Diagnostic Code 5257. Turning to Diagnostic Code 5259, pertaining to symptomatic removal of the semilunar cartilage, the Board finds that increased or separate ratings are not appropriate. The Veteran underwent meniscectomies of both knees in the 1960s, but there is no evidence of symptoms related to the removal of the semilunar cartilage that are separate and distinct from those already contemplated by the ratings above. The May 2011 VA examiner did not identify any abnormality of either meniscus and while the August 2017 VA examiner found that the Veteran's meniscus condition manifested frequent episodes of joint pain, this pain was attributed to osteoarthritis. The Veteran is therefore already compensated for his pain associated with arthritis by the assignment of separate 10% ratings noncompensable limitation of motion under Diagnostic Codes 5003, 5260, and 5261. The Board has considered the recent case of Lyles v. Shulkin, No. 16-09994 (Vet. App. Nov. 29, 2017), holding that the evaluation of a knee under Diagnostic Code 5260 or 5261, i.e. on the basis of limitation of motion, does not preclude a separate evaluation of a meniscal disability of the same knee under Diagnostic Codes 5258 or 5259 as a matter of law. However, in this case, the record does not establish any manifestations of a meniscal disability that are separate and distinct from those already contemplated by the diagnostic codes pertaining to arthritis and limitation of motion. Therefore, a separate rating is not appropriate under Diagnostic Code 5258 for either knee as it would violate the rule against pyramiding. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994); see also VAOPGCPREC 23-97 and VAOPGCPREC 09-98. In sum, the Veteran's right and left knee disabilities warrant separate 30 percent evaluations under Diagnostic Code 5262 for impairment of the tibia and fibula and separate 10 percent evaluations for noncompensable limitation of motion under Diagnostic Code 5003. The Board has considered whether there is any other schedular basis for granting other higher or separate ratings, but has found none. The Veteran has not demonstrated knee ankylosis or any episodes of dislocation or locking during the claims period and so Diagnostic Codes 5256 and 5258 are not for application. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against any separate or increased schedular ratings in addition to the ratings assigned above. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Compensation under 38 U.S.C. § 1151 The Veteran contends that compensation is warranted under 38 U.S.C. § 1151 for an additional cardiac disability incurred due to VA treatment at the Phoenix VAMC during the period from December 12, 2002 to December 2014. In essence, the Veteran contends that he incurred additional disability due to VA's failure to arrange for a cardiac catheterization for two days after he experienced an inferior MI. When a Veteran suffers additional disability or death as the result of training, hospital care, medical or surgical treatment, compensated work therapy, or an examination furnished by the VA, disability compensation shall be awarded in the same manner as if such additional disability or death were service-connected. 38 U.S.C. § 1151; 38 C.F.R. § 3.361. Under 38 U.S.C. § 1151, it is necessary to show that disability or death was the result of carelessness, negligence, lack of proper skill, error in judgment, similar instance of fault, or an event not reasonably foreseeable. After review of the evidence, the Board finds that the Veteran did not incur any additional disability due to VA medical care. Instead, the Veteran's current cardiac disability is solely due to the MI he experienced on December 12, 2002 without any additional disability incurred because of the two day period that elapsed before a cardiac catheterization was performed. Before addressing the Veteran's specific contentions in this case, the Board finds that a review of the relevant facts will prove useful. On December 12, 2002, the Veteran underwent a repair of an abdominal aortic aneurysm (AAA) at the Phoenix VAMC. Almost immediately after surgery, he sustained an inferior MI with ST elevation and acute hypotension. The Veteran was treated conservatively due to the recent surgical arterial incision and a hypotensive state, i.e. the presence of cardiogenic shock, which required intubation. An echocardiogram was performed and a cardiologist examined the Veteran at his bedside. The Veteran's ST elevations and hypotension were improving, but due to the recent AAA surgery and previous attempts to place a cordis in the right subclavian artery, the cardiologist found it was too dangerous to start thrombolytic therapy. The Veteran was instead started on a heparin drip, a beta blocker, medication, and serial monitoring of his cardiac enzymes and EKG results. A cardiac catheterization was planned for the next morning. The Veteran had no events or EKG changes overnight. The morning of December 13, 2002, he was described as stable, intubated, and responsive. He was extubated at approximately 8:15 AM and a cardiac catheterization was planned for that morning. A note from the attending cardiologist at 10:30 AM notes that the Veteran was hemodynamically stable with rapid resolution of the earlier ST changes. He was switched to an oral beta blocker and other medications; during another cardiac consultation two hours later, the Veteran was characterized as "stabili[z]ing nicely, and doing well." A cardiac catheterization was still planned for that day. However, throughout the day the Veteran's cardiac enzyme levels steadily rose and the Veteran complained of persistent chest pain. At 9:30 PM, the Veteran's surgical resident noted that cardiac catheterization was still indicated, but VA did not have the capacity to perform the procedure. The Veteran therefore required transfer to a facility where a coronary angiogram could be performed. An hour later, a VA cardiologist wrote that the Veteran had been accepted for transfer by Dr. Maki of Biltmore Cardiology, but there were no intensive care unit (ICU) beds available at Good Samaritan or St. Joseph's Hospital and Medical Center (St. Joseph's). The Veteran's chest pain was subsiding on medication and once an ICU bed was available at Good Samaritan, the Veteran would be transferred. The morning of December 14, 2002, a surgical resident noted that the Veteran still required a cardiac catheterization, but a transfer to Good Samaritan or St. Joseph's was not possible as there were still no unit beds. The Veteran would be transferred "as soon as [a] unit bed [is] available." By 10:00 AM, the Veteran's attending physician again noted that there were no beds available at Good Samaritan or St. Joseph's, but additional facilities (named as St. Luke's and Arizona Heart) could be contacted. A short time later, the Veteran's cardiologist stated that while the Veteran had been accepted the day before for a catheterization at Good Samaritan, a delay with the transfer was caused by the lack of availability of beds in that facility's ICU. However, because of the Veteran's ongoing angina, the VA cardiologist spoke to Dr. Gordon, a partner of Dr. Maki at Biltmore Cardiology, and arranged for the acceptance of the Veteran's emergent transfer straight into the Good Samaritan catheterization laboratory as soon as possible. The Veteran was transferred to Good Samaritan just before noon on December 14, 2002 and a cardiac catheterization and coronary angiography were performed that afternoon. The surgical report states that "the culprit lesion was obviously the right coronary artery." After the cardiac catheterization, the Veteran returned to the Phoenix VAMC for his post-operative recovery. He was discharged on December 17, 2002 and the discharge note states that a transfer of the Veteran to a private facility earlier than December 14, 2002 was not possible due to unavailability of ICU beds at any facility. After his catheterization, the Veteran was stable and his chest pain resolved. He was advised to follow-up with his vascular physician and cardiologist in two to three weeks. In sum, the Veteran underwent an AAA repair on December 12, 2002 and experienced a postoperative inferior MI. Two days elapsed before the Veteran was transferred to a private facility due to the unavailability of cardiac catheterization at the VAMC and a lack of beds in the ICUs of various private hospitals. The Veteran contends that he incurred an additional heart disability due to VA's failure to provide appropriate and timely treatment and such failure was negligence. The Veteran's VA medical records document the steps taken to treat his MI from December 12, 2002 to December 14, 2002 and clearly show that a cardiac catheterization was not available at an earlier date or time. In the immediate aftermath of his MI on December 12, 2002, his situation was not stable and certain types of treatment were deemed dangerous by his cardiolist. His physicians initially planned to perform the catheterization the morning of December 13, 2002, but treatment records from that day specifically note that VA did not have "the capacity to do this right now." Multiple attempts were made for the immediate transfer of the Veteran to a private facility throughout the day on December 13, 2002 and the morning of December 14, 2002, but no facility had ICU beds available. Finally, after speaking directly to a private cardiologist, VA arranged for the Veteran's transfer directly to the catheterization laboratory at Good Samaritan. The Veteran maintains that his wife had to intervene to arrange his transfer to Good Samaritan on December 14, 2002, but there is no evidence or record of this in the VA or private clinical documents. Rather, the arrangements were made between the Veteran's VA physician and the physicians at Biltmore Cardiology, including Drs. Gordon and Maki. Throughout the two days the Veteran remained at the Phoenix VAMC before his transfer, he was treated regularly and often and his status was consistently monitored by nursing staff, cardiologists, and the attending physicians. As noted above, the threshold issue in claims for compensation under 38 U.S.C. § 1151 is whether the Veteran incurred an additional disability due to VA hospital care, medical, or surgical treatment. The Veteran testified during the February 2017 hearing that he was told a MI was a possible risk of his AAA surgery on December 12, 2002. His testimony and statements throughout the claims period clarify that he does not claim the post-operative MI itself was the additional disability that was incurred due to VA care; rather, he contends that he incurred an additional heart disability due to VA's failure to provide a cardiac catheterization in the two days that elapsed between the onset of his MI and eventual treatment at Good Samaritan. After review of the evidence, the Board finds that the record does not establish that an additional cardiac disability was incurred due to VA treatment during the period from December 12, 2002 to December 14, 2002. The Veteran's medical records do not support a finding that he incurred an additional cardiac disability due to VA treatment from December 12, 2002 to December 14, 2002. He has not required consistent post-MI cardiac medical treatment and has remained very active throughout the claims period. Treatment records document the need for continuous heart medication, but the Veteran's cardiac condition has not required much intervention aside from follow-up cardiology appointments. In February 2007, the Veteran was noted by a VA physician to experience "rare" episodes of heart pain with exertion, but experienced relief with nitroglycerin. In June 2014, his VA cardiologist declined to schedule a consultation, noting that it was not needed. In December 2011, a VA physician who reviewed the complete record, including the Veteran's contentions, noted that an immediate post-MI echocardiogram in December 2002 was functionally identical to the Veteran's current echocardiogram with no worsening of heart function. This evidence indicates that the Veteran did not incur any additional disability of his heart after the December 12, 2002 MI. The record also contains a VA medical opinion weighing against the finding of an additional disability. After physically examining the Veteran and reviewing the claims file, an August 2017 VA examiner concluded that the Veteran did not incur any additional disability due to VA treatment in December 2002. The examiner noted that echocardiograms performed following the MI at the Phoenix VAMC on December 12, 2002, at the Good Samaritan catheterization laboratory on December 14, 2002, from the Phoenix VAMC in 2003, and in March 2017 all showed the same wall motion abnormality, defect, and ejection fracture. The absence of any change or progression in the Veteran's heart from the onset of the MI to the present time established that no additional disability was incurred due to VA treatment. The Board notes that the August 2017 medical opinion was rendered following an extensive review of the Veteran's VA and private medical records, and also considered the Veteran's specific contentions. It was also accompanied by a fully explained and well-reasoned rationale. The Board therefore finds that the medical opinion of the August 2017 VA examiner is entitled to substantial probative weight. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The Board has considered the statements of the Veteran that an additional disability was incurred due to VA's failure to provide a cardiac catheterization prior to December 14, 2002. However, as a lay person, he is not competent to render medical opinions. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999). The Board acknowledges that the Veteran is competent to testify as to observable symptoms, but notes that during the February 2017 hearing, he did not describe experiencing any cardiac symptoms and only stated that his disability required continuous medication. Based on the above, the Board finds that he is not competent as a lay person to establish the presence of a cardiac disability in addition to that associated with his December 12, 2002 post-operative MI. The competent evidence of record therefore weighs against a finding that the Veteran incurred an additional disability due to VA medical treatment after a MI from December 12, 2002 to December 14, 2002. As the Veteran did not incur an additional disability as a result of VA treatment, the claim for compensation under 38 U.S.C. § 1151 must be denied. 38 U.S.C. § 5107. ORDER Entitlement to a rating in excess of 30 percent for residual recurrent dislocation of the right patella with chondromalacia is denied. Entitlement to a separate 10 percent rating, but not higher, for right knee arthritis with painful motion (previously characterized as limitation of extension of the right knee) throughout the claims period is granted. Entitlement to a rating in excess of 30 percent for residual recurrent dislocation of the left patella with chondromalacia is denied. Entitlement to a separate 10 percent rating, but not higher, for left knee arthritis with painful motion throughout the claims period is granted. Entitlement to compensation under the provisions of 38 U.S.C. § 1151 (2012) for additional heart disability caused by VA treatment from December 12, 2002 to December 14, 2002 at the Phoenix VA VAMC is denied. ____________________________________________ M. H. Hawley Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs