BVA9416214 DOCKET NO. 91-17 324 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a left knee disorder secondary to the residuals of a shell fragment wound to the right knee. 2. Entitlement to service connection for a back disability secondary to the residuals of a shell fragment wound to the right knee. 3. Entitlement to service connection for the residuals of frozen feet. 4. Entitlement to an increased rating for the residuals of a shell fragment wound to the right knee, including post-traumatic arthritis, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARINGS ON APPEAL The appellant and his wife ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The veteran had active service from June 1943 until January 1946. His military occupational specialty was medical aidman. This matter comes before the Board of Veterans' Appeals (the Board) from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), in St. Petersburg, Florida. The procedural history of this case was set forth in a remand decision in November 1991 and will not be repeated except to note that claims for service connection for heart disease and for diverticulosis were withdrawn from appellate consideration. In a February 1993 letter the veteran indicated that he had been instructed to stop taking anti-inflammatory medication because it had caused a stomach ulcer. If the veteran contends that he was taking anti-inflammatory medication because of a service- connected disability, i.e., residuals of a shell fragment wound of the right knee with post-traumatic arthritis, he should clarify whether he is claiming service connection for a stomach ulcer. CONTENTIONS OF APPELLANT ON APPEAL It is contended that due to the veteran's service-connected right knee disability he developed an abnormal gait which has caused disability of the left knee and low back, including arthritis. It is asserted that he first developed problems with his left knee and low back in the late 1960's and that he now has bilateral varus deformity of the knees due to which bilateral total knee replacements have been recommended. It is maintained that private physicians have informed him that his disabilities of the left knee and low back are due to his service-connected right knee disorder. It is averred that in a winter campaign in Europe during World War II he sustained frozen feet with a change in the skin color. It is maintained that he self-administered on morphine for three days and that he has continuously had symptoms of frostbite since service and which eventually forced him to moved to a warm weather climate. It is contended that he sustained a through-and-through shell fragment wound of the right knee with a significant loss of muscle tissue and has a retained foreign body in the knee joint as well as severe arthritis. It is asserted that he has had surgery on his right knee as well as ultrasound treatment to remove calcium deposits but that he can no longer take anti-inflammatory medication for relief of pain. It is maintained that he now uses a cane as an aid in ambulation, receives outpatient treatment, has used an elastic brace, and is a candidate for a total right knee replacement. It is also averred that he was unable to maintain his occupation as a car salesman and was forced to take a more sedentary job. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claims for service connection for a left knee disorder and a back disorder, claimed as secondary to service-connected residuals of a shell fragment wound of the right knee, but that the preponderance of the evidence is in favor of the claim for service connection for residuals of frozen feet and for the assignment of a 30 percent schedular evaluation for residuals of shell fragment wound of the right knee, including post-traumatic arthritis. FINDINGS OF FACT 1. The veteran had active service from June 1943 until January 1946 and his military occupational specialty was a medical aidman. 2. Disability of the left knee and low back is first shown years after active service but is not causally or etiologically related to the veteran's service-connected residuals of a shell fragment wound of the right knee. 3. The veteran has residuals of frozen feet which were incurred during active service. 4. The veteran sustained a through-and-through shell fragment wound of the right knee which severed the popliteal artery and the head of the gastrocnemius muscle causing a severe injury of Muscle Group XI. CONCLUSIONS OF LAW 1. A left knee disorder is not proximately due to or the result of service-connected residuals of a shell fragment wound to the right knee, including post-traumatic osteoarthritis. 38 C.F.R. § 3.310(a) (1993). 2. A low back disability is not proximately due to or the result of service-connected residuals of a shell fragment wound to the right knee, including post-traumatic osteoarthritis. 38 C.F.R. § 3.310(a) (1993). 3. Residuals of frozen feet were incurred during active service. 38 U.S.C.A. §§ 1110, 1154(b) (West 1991); 38 C.F.R. §§ 3.303, 3.304(d) (1993). 4. A 30 percent schedular evaluation for residuals of a shell fragment wound to the right knee, including post-traumatic osteoarthritis, is warranted but an evaluation in excess thereof is not warranted on either a schedular or extraschedular basis. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.40, 4.41, 4.45, 4.47, 4.49 through 4.54, 4.56, 4.71, 4.72, 4.73 and Diagnostic Code 5311 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran's claims are plausible and thus well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991) which mandates a duty to assist the veteran in developing all pertinent evidence. The case was remanded in November 1991 to, in part, allow the RO the opportunity to obtain the records of Esther Roehr, M.D. Thereafter, the veteran executed and returned the necessary authorization forms for obtaining those records which were in the possession of Kenneth Ballard, M.D. However, correspondence received in March 1992 reveals that Dr. Ballard did not have any records of Dr. Roehr. The case was also remanded to afford the veteran VA orthopedic and vascular examinations which were conducted in December 1991. It is asserted that the VA orthopedic examination of December 1991 was inadequate because he was not asked to walk without a cane; and was conducted without the benefit of the claims folder being available and prior to X-ray studies which were taken after the examination; and erroneously reported that he could bend over with his knees stiff and touch his toes (which he claims he could not do without bending his knees), and that he had had only one episode of sudden swelling of a foot when, in fact, he has had several episodes. In this connection, VA examining physicians have latitude in exercising their discretion in conducting a proper examination in each individual case. Allin v. Brown, 6 Vet.App. 207, 214 (1994). Additionally, 38 C.F.R. § 4.1 (1993) provides that both in the examination and in the evaluation of disability, each disability is to be viewed in relation to its history. 38 C.F.R. § 4.2 provides that if a diagnosis is not supported by the findings on examination report or if the report does not contain sufficient detail, it should be returned as inadequate. The report of the VA orthopedic examination in December 1991 does not reflect on its face that the claims folder was available for review prior to the examination. On the other hand, a history of the veteran's disability was noted, including the shell fragment wound during service with debridement and surgery, the development of degenerative arthritis in the late 1960's, medication for pain, past ultrasound therapy, and the veteran's reported history of having developed disability of the left knee and leg due to the service-connected shell fragment wound of the right knee. It was also noted that he had had surgery in 1971 as well as frozen feet during service. Detailed examination findings were reported and the diagnoses included not only the disability of the right knee but also degenerative arthritis of the left knee and lumbar spine and cartilage deterioration of both knees causing bowing. While it is true that the examination was conducted prior to X-rays of the lumbosacral spine and knees, those X-rays merely confirmed the presence of degenerative joint disease which had been diagnosed. The examiner did not indicate that there was any insufficiency in the history related by the veteran at that time and the history recorded is consistent with his contentions and the evidentiary record. Moreover, there is no reason to contest the finding of the examiner that flexion of the back with the knees stiff and hands extended was such that the veteran could touch the tips of his toes with his fingers, even though the veteran contends that this was an erroneous finding. Further, even if he was not asked to walk without a cane, the examiner indicated that the veteran had a slight limp and slight bowing of the legs even with the use of the cane as an aid in ambulation. Accordingly, the abnormality of the veteran's gait, which is a primary thrust of his contentions on appeal, was taken into account by the examiner. As to the VA peripheral examination in December 1991, even if the recorded history of the veteran having had only one episode of sudden swelling of a foot is erroneous, this is no more than harmless error, for reasons which will become obvious. Lastly, on page 6 of the VA Form 1-646, of March 1991, the veteran's service representative indicated that the veteran had provided colored photographs of his right knee. A review of the evidentiary record does not reveal that any such photographs have been submitted. Moreover, the description of the initial injury as well as the residuals of the shell fragment wound during service are, in our judgment, sufficient for rating purposes. Service Connection for Left Knee and Low Back Disabilities Although the examination for entrance into military service in April 1943 disclosed that the veteran had first degree bilateral pes cavus, which was not considered to be disqualifying for service, the service medical records are negative for disability of the left knee, back, and feet. It is neither shown nor contended that the veteran developed disability of the left knee or low back prior to the late 1960's. The only contention is that disability of the left knee and low back are secondary to the veteran's service-connected residuals of a shell fragment wound of the right knee, including post-traumatic arthritis. Accordingly, as to these claims, this decision will be limited solely to the issue of entitlement to service connection on a secondary basis. Service connection is to be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). In Tobin v. Derwinski, 2 Vet.App. 34, 39 (1991) the United States Court of Veterans Appeals (the Court) held that where there was evidence that a disability for which service connection was claimed was not originally caused by the service-connected disorder but was aggravated by the service-connected disorder "[t]hat aggravation constitutes an increase [which] shall be service-connected." However, in Leopoldo v. Brown, 4 Vet.App. 216, 218-19 (1993) the Court held that when a service-connected disorder aggravates but is not the proximate cause of a nonservice-connected disorder, service connection is not warranted for the increment in severity of the nonservice-connected disorder. During service the veteran sustained a through-and-through shell fragment wound to the right popliteal region which severed the head of the gastrocnemius muscle. There is no evidence of a fracture nor is there any evidence of involvement of the joint space, contrary to the suggestions of the veteran. The wound was described as severe and was debrided. There was secondary closure of the wound, consistent with a loss of a significant degree of soft tissue, and the knee was casted. There was a medial entrance wound in the popliteal space and a lateral exit wound in the upper third of the lower leg. On VA examination in 1947, the scars were described as slightly adherent and tender when stretched but there was no limitation of motion of the right knee from the scarring and the veteran's gait was normal. The wound was described as mild. Subsequently, he had some increase in the severity of his right knee disability in the late 1960's and had right knee surgery in 1971. In an August 1981 statement, Dr. Roehr indicated that there had been good results from the surgery and a VA outpatient treatment (VAOPT) record of March 1987 indicated that although the veteran had right knee pain on prolonged standing which was unchanged, his right knee was better since his post service knee surgery. On VA examination in 1982 it was indicated that the surgery had been a medial meniscectomy but Dr. Kiesel reported in May 1990 that the surgery had consisted of debridement of the knee joint with removal of calcium deposits, shell fragments, and bony spurs. The VA examination in 1982 noted that there was a 4 3/4-inch long incisional scar in the medial aspect of the knee and that all scars of the right knee were nonadherent and nontender. The VA examinations of December 1947 and January 1982 indicate that the veteran's gait was normal and the latter examination found that the ligaments of his right knee were intact with good stability, although there was limitation of motion of the right knee. His leg lengths were equal and there was no muscular atrophy or weakness of the lower extremities. After the VA 1947 examination there is no contemporaneous clinical evidence prior to the August 1981 statement of Dr. Roehr. However, since that time, the evidence, overall, establishes the veteran has developed a bilateral genu varum (bowed legs) deformity as well as calcium deposits and arthritis of both knees with consequent narrowing of the lateral compartment of each knee from the bilateral genu varum deformity. He has also developed arthritis of the lumbosacral spine. The August 1981 and November 1988 statements of Dr. Roehr merely reflect treatment for disability of the veteran's right knee since July 1969 as well as treatment for disability of both knees since August 1972. In a May 1990 statement, Dr. Kiesel indicated only that he had examined the veteran in that month but did not indicate that there had been any earlier treatment of the veteran for any disability. It was recorded by Dr. Kiesel in May 1990 that the veteran had very severe osteoarthritis of both knees "probably stemming from his injury in World War II." On the other hand, in a June 1992 statement, Dr. Kiesel indicated that "[t]he left knee has osteoarthritis probably from a pre-disposition to the disease which obviously he has plus using that knee in a harder fashion since he has favored his right knee most of his life." The June 1992 statement is not consistent with the earlier statement in May 1990 because the May 1990 statement did not state that the veteran had a predisposition to osteoarthritis. In other words, the May 1990 statement suggests (i.e. 'probably'), without any stated basis, but does not actually state that there is a direct causal relationship, whereas the June 1992 statement does not. The latter statement only states that the service-connected right knee disorder was a contributory factor in the development of left knee disability. Moreover, Dr. Keisel's conclusion in June 1992 was based on the veteran's favoring his right knee "most of his life;" however, this premise is faulty since examinations in 1947 and as late as 1982 show a normal gait, not a limp which would result from favoring the right knee. The VA examiner in December 1991 diagnosed cartilage degeneration of both knees as the cause of the veteran's bilateral genu varum deformity and also diagnosed degenerative arthritis of the left knee and lumbar spine. The examiner opined that there did not appear to be a causative relationship between the right knee disability and the subsequent development of degenerative arthritis of the left knee and lumbar spine. In this connection, the shell fragment wound of the right knee did not cause any intrajoint injury, cartilaginous damage (now associated with lateral knee bowing) or any loss of bone substance with resultant shortening of a bone. Under 38 C.F.R. § 4.44 (1993) "[w]ith shortening of a long bone, some degree of angulation is to be expected - the extent and direction to be brought out by X-ray and observation. The direction of angulation and the extent of deformity should be carefully related to strain on the neighboring joints, especially those connected with weight- bearing." Similarly, 38 C.F.R. § 4.58 (1993) states that with shortening of a bone, arthritis developing in the same extremity or both lower extremities, with indications of earlier, or more severe arthritis in the injured extremity, including arthritis of the lumbosacral joints and lumbar spine, if associated with leg shortening, will be considered service-connected. However, in this case not only is there no leg shortening which would result in angulation and the development of the bilateral genu varum deformity, the VA X-rays of the veteran's knees in December 1991 indicate that the degenerative arthritis was severe in each knee. Thus, the presence of arthritis of the same degree in each knee militates against concluding that arthritis developed earlier in the right knee. It has been requested that the opinion of Dr. Kiesel be given equal weight to the opinion rendered by the VA examiner in December 1991. However, as indicated, Dr. Kiesel has essentially rendered two opinions. The first, in May 1990, was only conclusionary in nature. The second opinion in 1992 does not support the veteran's claim inasmuch as it indicates that the service-connected disability of the right knee only aggravated or was a contributory cause, together with a predisposition to arthritis, but was not the sole proximate cause of current disability of the left knee, and it rested on a faulty premise. Moreover, neither of the private physicians who have treated and evaluated the veteran have rendered an opinion that any arthritis or other disability of the lumbosacral spine is causally or etiologically related to the veteran's service-connected disability of the right knee; whereas, the VA examiner in December 1991 opined that there was no such relationship. Accordingly, the medical evidence weighs against concluding that disability of the left knee and lumbosacral spine is proximately due to or the result of the veteran's service-connected residuals of a shell fragment wound of the right knee, including post- traumatic arthritis of the right knee. Service Connection for Residuals of Frozen Feet With respect to the claim for service connection for residuals of frozen feet, the veteran sustained a shell fragment wound to the right popliteal space during military service. Under 38 C.F.R. § 4.62 (1993) circulatory disturbances, especially of the lower extremity following injury in the popliteal space, must not be overlooked and are generally rated as phlebitis. However, in this case there is no evidence that the veteran now has or has ever had phlebitis of any lower extremity. Service connection is to be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. This requires a finding that there is a current disability which has a definite relationship with an injury or disease or some other manifestation of disability during service. Rabideau v. Derwinski, 2 Vet.App. 141, 143 (1992) and Cuevas v. Principi, 3 Vet.App. 542, 548 (1992). However, it need not be shown that a disability was present or diagnosed during service but only that there is a nexus between the current condition and military service, even if first diagnosed after service, on the basis of all evidence, including pertinent service medical records. This can be shown by establishing that the disability resulted from personal injury or disease suffered in line of duty. 38 C.F.R. § 3.303(d) (1993); Godfrey v. Derwinski, 2 Vet.App. 352, 356 (1992). The veteran contends, and his service medical records corroborate, that he served in a cold environment while in combat in Europe during World War II. Under 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) satisfactory lay or other evidence of an injury or a disease incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service, even if there is no official record of such incurrence or aggravation. The veteran's statements that he sustained a frostbite injury of his feet in combat in World War II are credible. In December 1988 the RO denied service connection for residuals of frozen feet only on the basis that such residuals had not been found on the VA examination of November 1988. Although there is no service clinical evidence of incurrence of frostbite injury of the feet, the VA examination in 1988 indicated that the symptoms of the veteran's feet were primarily of coolness, especially with changes in weather. Although the vascular examination revealed no clear deficit, the examiner went on to indicate that the "changes" might be secondary to the episode of frostbite during service. This statement lacks clarity but the Board observes that the VA peripheral vascular examination of December 1991 revealed the veteran's feet to be cold and discolored with purplish mottling. When raised, the color disappeared but when the feet were in a dependent position, the coloring became worse. Similarly, a report of an examination by a private physician at the St. Petersburg Medical Clinic in August 1993 found edema and mild brawny induration of the veteran's feet consistent with stasis dermatitis, spider and varicose veins of the lower extremities. While there was no diagnosis reported by the private examiner, the diagnosis following the VA peripheral vascular examination in December 1991 was frostbite of the feet in 1944 with resulting pain in the feet when the feet became warm. In this case, on the VA peripheral vascular examination in December 1991 it was noted that the veteran undoubtedly had generalized arteriosclerosis without claudication. This may account for some circulatory disturbance in the veteran's lower extremities. Moreover, the private physician did not attribute the brawny induration, stasis dermatitis or varicose veins to frostbite injury. However, the 1988 VA examination reflected coolness of the feet and the 1991 VA examination attributed pain in the feet with excessive warmth to residuals of frostbite. It is therefore likely that the findings on the VA examinations reflect residuals of frostbite of the feet. While the Board notes that any changes of generalized arteriosclerosis have not been attributed to frostbite, and, therefore, are not included in this grant of service connection, it is the determination that the veteran does have some residuals of frostbite of the feet and that service connection is warranted for those residuals. Increased Rating for Residuals of a Shell Fragment Wound to the Right Knee, including Post-Traumatic Arthritis Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The higher of two evaluations will be assigned if the disability picture more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. An extraschedular evaluation will be assigned if the case presents an unusual or exceptional disability picture with such related factors as marked interference with employment or frequent periods of hospitalization such as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). In this case the 20 percent rating assigned by the RO to the service-connected residuals of a shell fragment wound to the right knee, including post-traumatic arthritis, is assigned not on the basis of limitation of motion of the right knee nor for any muscle injury from the shell fragment wound. Rather, the rating is assigned by analogy as recurrent subluxation, lateral instability or other impairment of the knee. The 20 percent rating encompasses moderate impairment and a 30 percent rating is assigned when such impairment is severe. In Pernorio v. Derwinski, 2 Vet.App. 625, 629 (1992) the Court held that "when.. it is necessary for the VA to evaluate [a service- connected disorder] under codes for similiar disorders [ i.e., by analogy under 38 C.F.R. §4.20 (1992) or using a built-up code under 38 C.F.R. § 4.27 (1992)] ... the Board should explain ... the diagnostic code under which the claim is evaluated, and, ... any inconsistencies, apparent or real, that result when the Board cites a code different from that used ... at other times in the history of the adjudication of the claim, including codes used by the agency of original jurisdiction or cited in the Statement of the Case." 38 C.F.R. § 4.20 (1992) specifically states, in part, that as to unlisted conditions "it will be permissible to rate under a closely related disease or injury." 38 C.F.R. § 4.27 (1992) states that "[n]o other numbers than these listed [in the rating schedule] ... are to be employed for rating purposes [ with the exception of unlisted conditions, which are to be assigned a built-up code]." Noting these regulations, the Court held in Suttman v. Brown, 5 Vet.App. 127, 134 (1993) that "[a]n analogous rating thus may be assigned only where the service-connected condition is 'unlisted'." The requirement that the VA consider and discuss selection of diagnostic code is heightened where the disability is listed in the rating schedule but has been rated by analogy under 38 C.F.R. § 4.27 (1992). Suttman v. Brown, 5 Vet.App. 127, 134 (1993) and Horowitz v. Brown, 5 Vet.App. 217, 224 (1993). Inasmuch as the initial shell fragment wound, described above, severed the head of the gastrocnemius muscle and the fact that the veteran now has arthritis, which is rated on the basis of limitation of motion of the affected joint, the proper rating assigned it should be either on the basis of the muscle injury or limitation of motion and not for recurrent subluxation or instability since his ligaments are intact and stable. VA examinations in January 1982 and December 1991 confirm that the veteran's arthritis of the right knee is the result of trauma, although as indicated there is no evidence of direct bony injury within the joint space of the right knee. When substantiated by X-ray findings, traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (1993). Degenerative arthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5003. Read together, 38 C.F.R. §§ 4.40 and 4.45 make clear that pain, supported by pathology and behavior, must be considered capable of producing compensable disability of the joints. Schafrath v. Derwinski, 1 Vet.App. 589, 592 (1991). 38 C.F.R. § 4.71a, Diagnostic Code 5003 provides for the evaluation of degenerative arthritis, when documented by X-rays, on the basis of a compensable or noncompensable degree of limitation of motion or, in certain circumstances, when there is no limitation of motion. Limitation of motion must be objectively confirmed by swelling, muscle spasm or satisfactory evidence of painful motion. If the degree of limitation of motion is compensable under the appropriate diagnostic code for the part affected, it is rated under that code. When there is a noncompensable degree of limitation of motion under the appropriate diagnostic code or even no limitation of motion, a minimum rating of 10 percent is warranted if there is dysfunction due to pain. When there is no limitation of motion and no dysfunction due to pain, 10 percent is assigned when there is X-ray evidence of arthritis of 2 or more joints or minor joint groups, and 20 percent if there are occasional incapacitating exacerbations. A 20 percent evaluation for limitation of motion of the knee is assigned where extension is limited to 15 degrees or flexion is limited to 30 degrees. A 30 percent evaluation is assigned where extension is limited to 20 degrees or where flexion is limited to 15 degrees. 38 C.F.R. § 4.71, Diagnostic Codes 5260 and 5161. Both the VA orthopedic examination in December 1991 and the examination by Dr. Kiesel in May 1990 found that the veteran had flexion of the right knee to 80 degrees which is a noncompensable degree of limitation of motion (normal flexion being to 140 degrees, 38 C.F.R. § 4.71, Plate II) under Diagnostic Code 5260. Dr. Kiesel's examination in May 1990 found that extension of the veteran's right knee was to 5 degrees which is also a noncompensable degree of limitation of motion (normal extension being to zero degrees, 38 C.F.R. § 4.71, Plate II) under Diagnostic Code 5261. Accordingly, the schedular evaluation in excess of the 20 percent rating currently assigned is not warranted on the basis of limitation of motion. A 20 percent evaluation is warranted for a moderately severe injury of Muscle Group XI, which includes the gastrocnemius muscle, and a 30 percent evaluation is warranted when the injury is severe. 38 C.F.R. § 4.73, Diagnostic Code 5311. In this case, the 20 percent evaluation assigned encompasses at least the minimum compensable rating of 10 percent due to functional loss or dysfunction as a result of pain as envisioned under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See Lichtenfels v. Derwinski, 1 Vet.App. 484, 488 (1991) and Schafrath v. Derwinski, 1 Vet.App. 589, 592 (1991). In evaluating a service-connected disorder, 38 C.F.R. § 4.2 provides that an examination report must be interpreted in light of the whole recorded history, reconciling the reports so that a current rating may accurately reflect the elements of disability present. The veteran's medical as well as industrial history since an injury as well as treatment and the reasons therefor over the years is also to be given attention. 38 C.F.R. § 4.41. Moreover, 38 C.F.R. § 4.10 provides that a full description of the effects of the disability upon a person's ordinary activity is required. Many factors are for consideration in evaluation of disabilities of the musculoskeletal system under 38 C.F.R. § 4.40. Functional loss may be due to absence or deformity of associated structures; or may be due to pain, supported by adequate pathology and evidenced by visible behavior during motion. Weakness is as important as limitation of motion. The principal symptoms of disability from muscle injuries are weakness, undue fatigue-pain, and uncertainty or incoordination of movement. Skin scars are incidental and negligible. Rather, it is the deep intramuscular and intermuscular scarring which is disabling. 38 C.F.R. §§ 4.50 and 4.54. Through-and-through or other wounds of the deep structure almost invariably destroy parts of muscle groups and bring about intermuscular fusion and binding by cicatricial and adherent muscle sheaths so that muscles no longer work smoothly but pull against fascial planes and other muscles so that delicate, coordinated movements are interfered with and there is loss of strength. Prolonged exertion brings about fatigue and pain, thus, interfering with function. 38 C.F.R. § 4.47. Disability of a muscle group is based on the ability of the muscle to perform its full work and not solely on its ability to move a joint. Tests of motion should be comparative as to the joint of the other extremity and made against gravity or resistance. 38 C.F.R. §§ 4.51, 4.52, and 4.53. Under 38 C.F.R. § 4.72 a through-and-through injury with muscle damage is always at least a moderate injury for each muscle group damaged. A muscle injury causing muscle or tendon damage as well as compound comminuted fracture establishes entitlement to a rating for severe muscle injury. A moderately severe injury encompasses a through and through or deep penetrating wound with debridement or with prolonged infection or sloughing of soft parts and intermuscular cicatrization. Objective findings include large entrance and exit scars indicative of injury of important muscle groups and indications of moderate loss of deep fascia or muscle substance. 38 C.F.R. § 4.56(c). A severe injury is envisioned when there are finding consistent with a moderately severe injury but also of explosive effect or shattering bone fracture with extensive debridement or prolonged infection. Objective findings include extensive, ragged, depressed, and adherent scars indicative of wide muscle group damage and moderate or extensive loss of deep fascia or muscle substance on palpation. 38 C.F.R. § 4.56(d). As indicated above, the veteran sustained a through-and-through shell fragment wound which severed the head of the right gastrocnemius muscle. Although he has a noncompensable degree of limitation of motion of the right knee under the appropriate codes, the arthritis and genu varum deformity of the right knee is of such severity that he has used an elastic knee brace, walks with the aid of a cane, and a total right knee replacement has been recommended. The degree of arthritic involvement of the right knee is described as severe and an X-ray of the right knee on VA examination in November 1988 revealed a small radiolucency consistent with the retention of a small metallic fragment. Moreover, he had additional post service surgery on his right knee and has received ultrasound treatment for calcium deposits from arthritis. Further, the description of the scars indicates a significant degree of tissue loss and, although the residuals of the wound were described as mild on VA examination in 1947, the initial service clinical records describe the wound as severe. Although 38 C.F.R. § 4.56(c), (d) would lead to a characterization of the veteran's disability as moderately severe, a 20 percent disability, overall, resolving all doubt in favor of the veteran and with consideration of the assignment of a higher schedular evaluation when, as here, the disability more closely approximates the criteria for that rating, it is the Board's determination that a schedular evaluation of 30 percent is warranted for residuals of a shell fragment wound of the right knee under 38 C.F.R. § 4.73, Diagnostic Code 5311. No higher schedular evaluation can be assigned under that diagnostic code and an evaluation in excess of the 30 percent rating is not warranted on an extraschedular evaluation inasmuch as he has not been hospitalized or had surgery on his right knee in recent years and in view of the fact that although a total right knee replacement has been recommended, he has only a mild degree of limitation of motion of the right knee. Further, he has remained employed for decades. Although he has taken a more sedentary form of employment, the evidence does not suggest that this is due solely to his service-connected right knee disability, as opposed to a combination of the service-connected right knee disorder and the nonservice-connected arthritis of the left knee and lumbosacral spine. In reaching these determinations, all doubt has been resolved in favor of the veteran's claims for service connection for residuals of frostbite of the feet and for an increased rating for the service-connected residuals of a shell fragment wound to the right knee, including post-traumatic arthritis, but it is the Board's determination that the preponderance of the evidence is against the veteran's claims for service connection for a left knee and low back disorder. Accordingly, as to those claims, there is no doubt to be resolved in favor of the veteran. ORDER Service connection for a left knee disorder and a low back disorder is denied but service connection is granted for residuals of frostbite of the feet and a 30 percent schedular evaluation is granted for residuals of a shell fragment wound to the right knee, including post-traumatic arthritis, subject to applicable laws and regulations governing the award of monetary benefits. HOLLY E. MOEHLMANN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.