Citation Nr: 22017754 Decision Date: 03/26/22 Archive Date: 03/26/22 DOCKET NO. 17-40 132A DATE: March 26, 2022 REMANDED Entitlement to a disability rating in excess of 30 percent for the service-connected left total knee replacement (TKR) is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from November 2001 to May 2002, with 22 years of prior inactive service in the Naval Reserve. This case comes to the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision of a Department of Veterans Affairs (VA). In October 2021, the Veteran testified at a virtual videoconference hearing before the undersigned. Entitlement to a disability rating in excess of 30 percent for the service-connected left TKR The Veteran contends that a rating higher than 30 percent is warranted for her left TKR, which is evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5055. Under that code, chronic residuals (of a prosthetic replacement) consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5260, 5261, or 5262, with a minimum rating of 30 percent. (Recent amendments to Code 5055, effective in February 2021, are inapplicable in this case.) The Veteran is seeking at least a 60 percent rating for her disability, asserting in August 2017 that it was manifested by symptoms of instability (causing her to fall and sustain fractures to include her left femur), pain, deformity, and problems with ambulating. The central complicating factor in evaluating the Veteran's left knee disability is the fact that during the pendency of the appeal she received a diagnosis of inclusion-body myositis (IBM) in October 2013 (after a muscle biopsy), which is a progressive disease that, in pertinent part, impacts the muscle function of her lower extremities. In a November 2013 statement, she stated the IBM "further contributes to the disability and aggravation of my already s/c left knee." In a March 2014 statement, she indicated she was in constant pain and used a knee brace for stabilization and a cane for ambulation but could not walk far. She also alleged both that her IBM was caused by her left TKR and that it was associated with her in-service left knee injury (when she stepped into a hole in the sidewalk and fell in March 2002). In a February 2018 statement, she asserted that essentially since her in-service injury she had never been free of knee pain and still had to use a cane to walk. In referring to a VA examiner, she asserted that the VA "uses the excuse of myositis as a cause for my pain" and claimed that she did not have IBM prior to her left TKR. At her Board hearing in October 2021, the Veteran (in a wheelchair) described severe pain and left leg weakness and stated she was unable to walk. When asked how much of her symptoms were attributable to her IBM, she appeared to minimize the impact of the IBM on her functioning, responding that her IBM affected her arms and "some in my legs, but not really in my legs but my getting up and down...the muscles at the top of my legs...will not function to let me lift myself up." She maintained that she had pain and instability in the left knee that was unrelated to her IBM. A review of the record shows that the Veteran underwent a left TKR in May 2010, and a February 2011 rating decision assigned a temporary 100 percent rating under Code 5055 from May 26, 2010 through June 2011, and a 30 percent rating from July 1, 2011. In July 2013, the Veteran filed a claim for a higher rating for her disability, asserting at the time that she had been having knee pain for about seven months together with severe weakness, about which she was consulting with an orthopedist and neurologist. She stated that she had fallen several times and used a cane for support that was of minimal assistance (so a knee brace was added for stability). Since her increased rating claim, she has filed additional VA claims, alleging that various disabilities were secondary to her left TKR on the basis that her knee weakness caused her to fall and resulted in fractures and other disability. For example, in March 2015, she claimed secondary service connection for a left (distal) femoral periprosthetic fracture and left leg shortness (denied in a May 2015 rating decision); in May 2019, she claimed secondary service connection for spondylosis of the lower back, left ankle disability, right ankle disability, and fractures of the left tibia and fibula (an August 2019 rating decision granted the low back and bilateral ankle claims as secondary to the left TKR); in September 2020, she claimed secondary service connection for right femur fracture (denied in a February 2021 rating decision); and in October 2020, she claimed secondary service connection for a right clavicle fracture (granted in a February 2021 rating decision). The medical evidence in the file indicates that in the years leading up to her left TKR, the Veteran underwent a VA examination in February 2007, which disclosed no instability but pain with limitation of motion and moderate degenerative joint disease of the left knee. Private treatment records document numerous falls onto her knees (she underwent a right TKR in 2006). After abrasion chondroplasty of the medial femoral condyle of the left knee in February 2010, the Veteran had continuing symptoms and thus underwent a left TKR in May 2010. Thereafter, VA and private records show continuing symptoms related to the left knee to include pain, swelling after prolonged activity, and numbness below the knee (the Veteran claimed that the numbness started from the time of her TKR). On an April 2011 VA physical therapy note, she reported she had been falling due to sudden weakness in her left lower extremity. Her left knee was evaluated by VA orthopedic surgery clinic from January 2012 to March 2012 due to complaints of routine falls secondary to weakness in the lower extremities (left worse than right), knee pain, and significant atrophy of the quadriceps. She had multiple X-rays (showing no loosening of her TKR), lab studies (showing no knee infection), and an EMG (showing lumbar disk protrusion and spinal stenosis); and strength testing results were 4/5 and 5/5, depending on the muscle tested. Private records show that in May 2013, the Veteran complained of pain and problems with her left knee since her TKR and reported that she gradually noticed increasing right upper extremity and lower extremity weakness for four months (a recent EMG study was noted as abnormal). At that time, there was left knee pain and bilateral lower extremity weakness. In June 2013, left knee pain was 5-6/10 without pain medications. In July 2013, left knee pain was 4/10 and strength was 4/5. She underwent a muscle biopsy and was informed in October 2013 of a diagnosis of IBM. In evaluating the Veteran's left knee in August 2016, a VA examiner found chronic residuals of the TKR consisting of severe painful motion or weakness, but she did not refer to, address, or otherwise appear to consider the Veteran's IBM. A November 2016 VA orthopedic note indicates that imaging showed that the implants of her left TKR were in place and well-fixed, and that there was valgus malunion of the left distal periprostatic femur fracture (healed in a poor position) with metal debris in the joint space. In February 2018, her private physician diagnosed malunion of the distal femur and short leg syndrome (left-sided) and prescribed shoe lifts. An October 2019 VA primary care note indicates that the Veteran had a history of falls due to muscle weakness from IBM and that she also had bilateral knee surgeries where the knees can buckle (especially on the left) and cause her to fall (e.g., within the past year she fell several times and fractured her right patella and head of the right femur). The record contains remarks and opinions relating to the impact of the Veteran's IBM and left TKR, which were delivered by different private physicians and VA examiners. A private physician, Dr. TB, wrote in a brief January 2014 statement to the VA that the Veteran's "disability status should be increased" on account of her progressive IBM. In a February 2014 statement, another private physician, Dr. JF, indicated that the Veteran had a "progressively untreatable condition" called IBM and a previous left TKR, and that "[t]his has caused her to become very unstable with her gait." He stated that she fell if she did not wear a brace and that her symptoms would continue to worsen. He stated that this had "caused significant weakness to her leg as well as causing her to have some increased knee pain because of the weakness of the quadriceps muscle." He concluded that the Veteran's condition would not improve and that she "probably has a greater disability to the leg than she did previously." In a September 2014 VA examination addendum report, the examining physician opined that the Veteran's IBM was an autoimmune disease of idiopathic origin and that there was no literature connecting it to her TKR. He stated it was very unlikely that the IBM was secondary to the TKR. Further, based on a physical examination, he remarked that the Veteran's weakness was not severe and her pain was moderate. In a May 2015 VA examination addendum report, another examining physician discussed the Veteran's IBM and found that, although she was diagnosed with IBM due to weakness after her knee replacements, IBM had no known cause and was "primarily causing [her] weakness and pain with movement." He observed that her IBM had progressed in the last several years from independence in walking to the necessity for such assistive devices as a walker, knee braces, and soon a motorized assistive device; he found such "progression of weakness and progression would [not] be accounted for by the knee replacement." He further asserted that her IBM would be the "major cause of any weakness, pain and or limitation in motion," and could not state whether she had any residuals for the left TKR (he noted it would be speculative unless she was "tested" before the IBM became "prominent," which occurred around the time of the TKR). A private pain clinic physician, Dr. MS, stated in November 2015 that given the Veteran's history of weakness and clumsiness that was "exclusively" of the left knee, he suspected that it was "related to the mechanics of the knee itself and not due to the dermatomyositis, which, if that were true, would be causing the weakness and buckling bilaterally" (but on examination, he observed that strength was moderately decreased in both quadriceps and deep tendon reflexes were "abolished" in both lower extremities). A VA examiner in June 2019 opined that the Veteran's diagnoses of low back, right ankle fracture, and left tibia/fibula fractures were the result of falls that occurred as a result of weakness related to the Veteran's left TKR, but the examiner did not mention, or address in any way, the Veteran's IBM. A different VA examiner in January 2021, in opining that the Veteran's right clavicle fracture from a fall was due to her left TKR, likewise did not mention, or address in any way, her IBM. The foregoing evidence is inconsistent and inconclusive on the matter of the severity of the Veteran's left TKR and the extent of its impairment, separate and distinct from the co-morbid IBM. Therefore, a medical opinion is needed to discern, if medically possible, the left TKR symptoms (and the severity of them) separate and apart from the IBM symptoms. The matter is REMANDED for the following action: Arrange for the claims file to be forwarded to an orthopedist, preferably an orthopedic surgeon, if possible, to determine the nature and severity of the Veteran's service-connected left TKR. If an in-person examination of the Veteran and/or further consult with a specialist in autoimmune diseases (such as those affecting muscles) is deemed necessary in order to answer the following questions, it should be arranged. The examiner should review the entire claims file, to include a copy of this remand. For the period beginning in July 2012, to the extent medically possible, the examiner is asked to (a) differentiate all residuals of the Veteran's left TKR from her nonservice-connected IBM, and (b) describe the severity of each residual left TKR symptom. To that end, the examiner should specifically opine whether the Veteran had chronic left TKR residuals consisting of severe painful motion or weakness in the left lower extremity, and if so, indicate from what approximate date (beginning in July 2012) it was ascertainable that the residuals became severe. If it is not medically (and factually) discernible to render such an opinion, the examiner should explain why not. The examiner should also address the Veteran's various allegations that her IBM was caused by her left TKR, that the IBM was associated with her in-service left knee injury (when she stepped into a hole and fell in March 2002), and that she had pain and instability in the left knee that was unrelated to her IBM. The examiner should also consider, and comment upon as necessary, the remarks and opinions relating to the impact of the Veteran's IBM and her left TKR, which were given by different private physicians and VA examiners in the record (to include those that are described, above, in this remand). See, e.g., the private statement of Dr. TB in January 2014; the private statement of Dr. JF in February 2014; the VA examiner's addendum report of September 2014; the VA examiner's addendum report of May 2015; the private treatment record of Dr. MS in November 2015; the June 2019 opinion of a VA examiner (who did not address IBM); and the January 2021 opinion of a VA examiner (who did not address IBM). The examiner must explain the rationale for all opinions, citing to relevant evidence, supporting factual data, and medical literature, as deemed appropriate. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Debbie Breitbeil, Counsel 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.