Citation Nr: 21003463 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 14-22 741 DATE: January 21, 2021 ORDER Entitlement to an initial disability evaluation in excess of 10 percent for left knee patellofemoral syndrome is denied. REMANDED Entitlement to service connection for a bilateral lower extremity neurological disorder, to include sciatica, is remanded. FINDING OF FACT Throughout the appeal period, the Veteran’s left knee patellofemoral syndrome has not manifested with limitation of flexion of 30 degrees or less. CONCLUSION OF LAW The criteria for an initial disability evaluation in excess of 10 percent for left knee patellofemoral syndrome are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5260. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1974 to October 1977. This matter comes before the Board of Veteran’s Appeals (Board) from a November 2012 rating decision that denied service connection for leg and groin pain and an April 2016 rating decision that granted service connection for a left knee patellofemoral disorder; issued by the Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board in August 2020 when the claims were remanded for development. The Board finds the August 2020 remand directives have been substantially complied with, and the matters are again before the Board. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to an initial disability evaluation in excess of 10 percent for left knee patellofemoral syndrome The Veteran seeks an initial disability evaluation in excess of 10 percent for her left knee patellofemoral syndrome with arthritis. As this appeal originates from disagreement with the initial rating assigned to the Veteran’s left knee disability, the appeal period is from the date of the effective date of the award of service connection for the condition, April 29, 2013, forward. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. To evaluate the level of disability and any changes in a condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Additionally, separate ratings for distinct periods of time, based on the facts may be for consideration. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part or all the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40; see also 38 C.F.R. §§ 4.45, 4.59. Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board notes that hyphenated diagnostic codes (DCs) are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. In addition, codes ending in “99” are for all unlisted conditions. When an unlisted condition is encountered, it is permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology, are closely analogous. 38 C.F.R. § 4.20. The Veteran’s left knee disability is rated under DCs 5010-5260. Under DC 5010, arthritis due to trauma is evaluated as degenerative arthritis under DC 5003, which provides that degenerative arthritis established by x-ray findings will be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (e.g., DC 5200, etc.). When however, the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate diagnostic codes, a rating of 10 percent is applicable to each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. DC 5260 is used to rate limitation of flexion of the knee. Under DC 5260, limitation of flexion of the knee to 45 degrees warrants a 10 percent rating; to 30 degrees warrants a 20 percent rating; and to 15 degrees warrants a 30 percent rating. Normal range of motion (ROM) for the knee is defined as flexion, 0 degrees to 140 degrees; and extension, 140 degrees to 0 degrees. 38 C.F.R. § 4.71, Plate II. Additionally, VA General Counsel has held that a veteran who has arthritis resulting in limited or painful motion and instability of a knee may be rated separately under DCs 5003 and 5257, cautioning that any such separate rating must be based on additional disabling symptomatology. See VAOPGCPREC 23-97 (1997); VAOPGCPREC 9-98, (1998). VA General Counsel has further held that separate ratings under 38 C.F.R. § 4.71a, DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004. Other diagnostic codes relating to the knee are DC 5256 (ankylosis), DC 5258 and 5259 (symptomatic dislocation and/or removal of semilunar cartilage), DC 5262 (impairment of tibia and fibula) and DC 5263 (genu recurvatum). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran’s medical records have been associated with the claims file. In September 2013, the Veteran was administered a VA examination for her knee condition. The examiner noted the Veteran reported pain and limited range of motion due to her pain; as well as flareups occurring 3- 4 times per week. The Veteran’s left knee was noted to have flexion limited to 125 degrees with objective evidence of painful motion noted at 115 degrees. No additional loss of motion was noted with at least 3 repetitions. Joint stability testing was performed with normal results. The Veteran was also noted to have arthritis in her left knee. No other pertinent findings were noted. See Knee and Lower Leg Conditions Disability Benefits Questionnaire (Knee DBQ), dated September 2013. In a February 2014 medical opinion, the Veteran’s private physician noted she reported progressively worsening pain since her military service related to her left knee, difficulty with stairs, standing or sitting with her bent knee for long periods of time; as well as flareups occurring 3- 4 times per week associated with increased use and weather changes. It was noted the Veteran takes ibuprofen and rests to control her pain. This letter also noted that the Veteran has less movement than normal in her knee, but no measurements were noted. See medical opinion of February 2014 associated with the claims file in April 2014. In December 2019, the Veteran was re-administered a Knee DBQ. The Veteran’s patellofemoral syndrome of the left knee diagnosis was noted. The Veteran reported pain flareups associated with her condition, with a frequency of “a couple of times per month”, a duration of 24 hours, triggered by activity such as going up stairs and prolonged walking, and with alleviating factors noted as rest and medication. The Veteran’s range of motion was noted to remain the same during these flareups. The Veteran’s left knee was noted to have a normal range of motion, with pain noted on flexion and causing functional impairment. The Veteran’s range of motion was noted to be reduced with at least 3 repetitions and measured at 130 degrees flexion. The examiner also noted that during flareups the Veteran’s range of motion was reduced to 130 degrees on flexion. No ankylosis, joint instability, effusion, shin splints, nor meniscal conditions were noted. The Board found this Knee DBQ inadequate for adjudication purposes in its August 2020 decision, as the examination report lacked information compliant with Correia. In October 2020, another Knee DBQ was administered to the Veteran. The Veteran’s reports of knee pain were noted, as well as her use of medication to control her pain when needed. The Veteran reported flareups 1-2 times a month, that precluded her from climbing stairs, due to pain, which she managed with medication. The Veteran denied emergency room visits or injections related to her left knee disability in the prior 12 months. The Veteran’s left knee initial range of motion was noted as abnormal, with flexion limited to 120 degrees. The Veteran did at least 3 repetitions, with no additional loss of function noted. The Veteran’s pain during flareups was noted to cause additional limitation of motion with flexion limited to 110 degrees. No ankylosis, joint instability, recurrent effusion, meniscal conditions, or any other additional conditions were noted. The examiner also noted, pursuant to the Board’s remand instructions, that the Veteran’s right knee examination revealed no pain on passive range of motion testing nor pain when the joint was used in non-weight bearing testing; however, the Veteran’s left knee examination revealed pain on passive range of motion testing, with no additional loss in range of motion to that noted, nor pain when the joint was used in non-weight bearing testing. See Knee DBQ of October 2020. The Board finds this examination adequate and assigns it high probative value. Based on all of the above, the Board finds that a disability rating in excess of 10 percent for the Veteran’s left knee disability is not warranted as the evidence of record does not support the finding that the Veteran’s condition has manifested with limitation of flexion of 30 degrees or less at any time during the appeal period; which would warrant the higher 20 percent evaluation under DC 5260. The Board notes that the Veteran’s representative asserted the Veteran suffers from instability which warrants a separate disability rating. See statements submitted with NOD of February 2017. However, throughout the available medical records, the Veteran has been found to have no instability regarding her left knee. Additionally, the Veteran has not reported at any time during her examinations that she suffers from joint instability or nor has she expressed any other complaints that could be construed to indicate she suffers from joint instability. Although the Veteran is competent to describe symptomatology and her representative could be competent to describe said symptomatology, the Board finds this statement not credible in light of the existing medical and lay evidence of record and assigns it no probative value. Accordingly, the Board finds the Veteran is not entitled to a separate disability rating for left knee instability, as the evidence of record does not support the finding that the Veteran has at any time during the appeal period suffered from instability in her left knee. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). However, the evidence of record does not support the finding that the Veteran currently has, or has had at any time of the appeal period ankylosis (DC 5256), recurrent subluxation or instability (5257), dislocated or symptomatic removal of cartilage (DCs 5258 and 5259), impairment of the tibia and fibula with malunion or nonunion (5262), or genu recurvatum (5263). Accordingly, the Board finds that no other diagnostic code is applicable in the present case or would result in a more favorable disability rating for the Veteran’s left knee disability. For the reasons expressed above, the Board finds that a disability rating in excess of 10 percent for the Veteran’s left knee disability is not warranted at any time during the appeal period and the claim must be denied. REASONS FOR REMAND Entitlement to service connection for a bilateral lower extremity neurological disorder, to include sciatica, is remanded. The Veteran seeks service connection for a bilateral lower extremity neurological disorder, to include as secondary to her service-connected lumbar sacral strain with lumbago. In favor of her claim, the Veteran has asserted that she suffers from leg pain, possibly sciatica, and that she also has pain in her groin area. See statement of April 2012. The Veteran’s representative also asserted that the Veteran believed her pain, which she experienced about 2 to 3 times a week, to be related to her back injury in service. See statements submitted with NOD of December 2012. The Veteran’s medical records have been associated with the claims file. Medical records for November 2010, show the Veteran complained of back pain that radiated to the back of her calf, but denied tingling or numbness in her lower extremities. See medical records for November 2010, associated with the claims file in April 2012. In the November 2011 Back Conditions Disability Benefits Questionnaire (Back DBQ), the Veteran reported no radiation of pain nor tingling in her legs. See Back DBQ of November 2011. In July 2013, the Veteran was administered a Nerve Conduction Study where no denervation was noted, the tibial and peroneal nerves were noted as normal and sensory nerve conduction study of the sural nerves was also normal. Accordingly, it was determined that there was no electrical evidence of radiculopathy or neuropathy in either leg. See medical records for July 2013, associated with the claims file in October 2013. In an April 2014 Back DBQ, the Veteran reported that her back pain reflected in her left groin and then across the anterior left thigh down to the lateral surface of her left thigh as far as her left knee. The examiner noted that mixed radicular dermatomes in this pain were indicated by the patient and therefore a radicular component to her back pain was not certain. The examiner further noted the Veteran’s complaints in the radiculopathy section of the examination report, characterizing them as mild radiculopathy in the left leg. No radiculopathy in the right leg was noted. See Back DBQ of April 2014. In May 2016, the Veteran was administered a Peripheral Nerves Conditions Disability Benefits Questionnaire (Nerves DBQ). The Veteran was diagnosed with left ilioinguinal neuropathy. The examiner noted that the Veteran’s left ilioinguinal neuropathy caused the pain in her groin and not her leg. The examiner clarified that neuropathy and radiculopathy were different concepts and that the clinical examination was suggestive of left ilioinguinal neuralgia causing her left groin pain. The examiner further pointed out that the Veteran also had a positive straight leg raise examination, which suggested mild left sciatica- consistent with the Veteran’s back arthritis on her L5-S1 spine level. The Veteran’s sciatica was noted as normal with no motor weakness noted. See Nerves DBQ of May 2016. Following the examination, the examiner opined that it was less likely than not that the Veteran’s left inguinal pain and her left posterior leg pain had its onset due to any in-service incident. The examiner explained that the Veteran's left groin pain is in the distribution of the left ilioinguinal nerve. The Veteran has a neuralgia in this left nerve distribution causing her pain on the medial side of her groin which is not related to service and the Veteran has maintained that the nerve pain occurred years after discharge. The examiner further opined that although the Veteran had some symptomatology consistent with sciatica, that the Veteran was at risk for such condition due to her back arthritis; which was not a result of the Veteran’s in-service incident. See medical opinion of May 2016. In June 2016, an addendum VA medical opinion was associated with the claims file. In this opinion, the examiner noted that left groin pain, related to left ilioinguinal nerve was neuropathy and not radiculopathy. The examiner noted that neuropathy is local and does not come from the spinal roots in the back; therefore, the pain was not related to the Veteran’s back condition. The examiner further noted that the Veteran’s neuropathy was due to local problems in the Veteran’s groin or vaginal area and there was not neuropathic pain in the groin area noted in the Veteran’s service treatment records. See medical opinion of June 2016. The examiner also noted that the Veteran had posterior leg pain consistent with left sciatica which is due to spinal root problems related to the natural advancement of the Veteran’s back arthritis. The examiner further opined that one incident of low back injury, as mild as the Veteran’s, does not cause advancing arthritis over the years; rather the Veteran’s arthritis occurred at its own natural rate and was not due to any injury incurred in service. See medical opinion of June 2016. The examiner also noted that although the Veteran complained of recurrent back pain in her report of medical examination for separation, that it was not clear what she meant in the report. It was also noted that the Veteran’s service treatment records showed the Veteran complained of sacral pain after giving birth vaginally but that nerve roots in the sacrum do not contribute to the groin or the posterior leg pain that the Veteran currently has. See medical opinion of June 2016. In December 2019, the Veteran was re-administered a Nerve DBQ. It was noted the Veteran presented with clinical signs of sciatica in the diagnosis section. The examiner determined the Veteran had mild incomplete paralysis of the sciatic nerve in her left lower extremity; as well as mild incomplete paralysis of the femoral nerve in the same extremity. No abnormalities for the right lower extremity were noted. The examiner also noted that following radiological evaluation of the Veteran’s spine and left hip, that the Veteran was noted to have interval progression of multilevel degenerative disc disease in her spine at the L3-4 through L5-S1 levels, as well as an enthesophyte on the left femoral head which could account for some of the Veteran’s leg pain and weakness, and that there was bilateral asymmetrical sacroiliitis of unknown etiology. See Nerve DBQ of December 2019. Following the examination, the examiner subscribed a medical opinion where she opined that the Veteran’s lower extremity neurological disorder was less likely than not related to her lumbar strain. In favor of her opinion, the examiner noted that the Veteran has signs and symptoms of left leg sciatica which is related to her progressive arthritis of the spine. The examiner also noted that the Veteran’s in-service incident of lumbosacral strain did not create the Veteran’s present arthritis but rather the Veteran has progressive arthritis due to the natural progression of aging or new disease. See medical opinion of December 2019. In June 2020, another VA medical opinion was associated with the claims file. The examiner opined that the Veteran’s worsening left sciatica is due to the natural progression of her arthritis and that the arthritis was not due to the Veteran’s service-connected lumbago, lumbar spine injury or knee. In August 2020, an addendum to the June 2020 VA medical opinion was associated with the claims file. In this opinion, a different examiner noted that after reviewing the evidence of record and the June 2020 medical opinion, that it was less likely than not that a lower extremity neurological disorder, to include sciatica, was caused or aggravated beyond its natural progression by the Veteran’s service connected left knee patellofemoral pain syndrome or lumbosacral strain with lumbago. The examiner did not offer a rationale for the opinion expressed. As the examiner who subscribed the August 2020 medical opinion did not include a complete rationale for the opinion expressed; the Board finds this opinion inadequate for adjudication purposes and finds a remand is necessary to obtain a new medical opinion. The matters are REMANDED for the following action: 1. Update medical records. All responses, including negative responses, must be associated with the claims file. 2. Obtain a medical opinion that addresses whether the Veteran’s claimed neurological disorder of the lower extremities is caused by or aggravated by the Veteran’s service-connected disabilities. After a thorough review of the claims file, the examiner should address the following: a. Whether it is at least as likely as not that the Veteran’s left leg pain, diagnosed as sciatica and/or radiculopathy is: i. proximately due to or ii. aggravated beyond its natural progression by any of her service-connected disabilities b. whether it is at least as likely as not that the Veteran’s groin pain, diagnosed as ilioinguinal neuropathy/neuralgia is: i. proximately due to or ii. aggravated beyond its natural progression by any of her service-connected disabilities c. whether it is at least as likely as not that the Veteran’s mild incomplete paralysis of the femoral nerve in her left lower extremity is: i. proximately due to or ii. aggravated beyond its natural progression by any of her service-connected disabilities d. Whether the Veteran currently has a condition or diagnosis related to her right lower extremity i. if so, whether it is at least as likely as not that any diagnosed condition in her right lower extremity is directly related to the Veteran’s service ii. whether any diagnosed condition in the Veteran’s right lower extremity is proximately due to or aggravated beyond its natural progression by any of the Veteran’s service-connected disabilities. It is left to the examiner’s discretion to determine whether a new examination of the Veteran is necessary in order to subscribe the requested opinions. The examiner is further advised that aggravation for legal purposes is defined as a worsening of the underlying disability beyond its natural progression versus a temporary flare-up of symptoms. The examiner is asked to provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion(s) without resorting to speculation, the report should expressly indicate this, and the examiner should explain why an opinion cannot be provided without resorting to speculation. If the inability to provide an opinion is the result of a need for additional information, the physician must identify the additional information needed. 3. After completing the above requested actions, and any additional notification and/or development deemed warranted, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, furnish to the Veteran and her representative an appropriate supplemental statement of the case that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Gonzalez-Maldonado The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.