BVA9502924 
DOCKET NO.  93-08 366     )       DATE
          )
          )

On appeal from the decision of the
Department of Veterans Affairs Regional Office in St. Paul,
Minnesota

THE ISSUE

Entitlement to a disability evaluation in excess of 10 percent
for laceration of the right knee with chondromalacia patella.

REPRESENTATION

Appellant represented by: Disabled American Veterans

WITNESS AT HEARING ON APPEAL

Appellant

ATTORNEY FOR THE BOARD

Christopher B. Moran, Counsel

INTRODUCTION

The veteran served on active duty from August 1981 to August
1985.

CONTENTIONS OF APPELLANT ON APPEAL

It is contended by the veteran that his service-connected
laceration of the right knee with chondromalacia is primarily
manifested by ongoing pain that increases on motion, episodes of
weakness and other symptoms limiting his ability to walk,
especially on certain surfaces.  He maintains that repetitive
motions such as climbing stairs aggravate his symptoms.

DECISION OF THE BOARD

In accordance with the provisions of 38 U.S.C.A. § 7104 (West
1991), the Board of Veterans' Appeals (Board)has reviewed and
considered all of the evidence and material of record
incorporated in the veteran's claims folder and for the following
reasons and bases hereinafter set forth, it is the decision of
the Board that the preponderance of the evidence is against the
claim of an increased evaluation for laceration of the right knee
with chondromalacia.

FINDINGS OF FACT

1.  All relevant evidence necessary for an equitable disposition
of the veteran's appeal has been obtained by the Department of
Veterans Affairs (VA) regional office (RO).

2.  The veteran's laceration of the right knee with
chondromalacia is productive of no more than slight knee
impairment with flexion limited to 125 degrees.

CONCLUSION OF LAW

The criteria for the assignment of a disability evaluation
greater than 10 percent for laceration of the right knee with
chondromalacia have not been met.  38 U.S.C.A. §§ 1155, 5107
(West 1991); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.20, 4.40, 4.71
(Plate II) and Part 4, Diagnostic Codes 5257, 5260, 5261 (1994).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

I.  Duty to Assist

Because the veteran's claim is plausible, it is "well grounded"
within the meaning of statute and judicial construction.
38 U.S.C.A. § 5107(a) (West 1991).  The VA, therefore, has a duty
to assist the veteran in the development of facts pertinent to
his claim.  In this regard, the veteran was afforded a VA
examination in December 1992.  Moreover, numerous private
treatment records from Duluth Clinic as well as a report of a
standard Polinsky Functional Capacity Assessment are on file.
The veteran attended a personal hearing before a hearing officer
at the RO in December 1992.  As it stands, the evidence of record
pertaining to the certified issue on appeal provides a sufficient
basis upon which to address the merits of the veteran's claim.
There was no indication that there are additional outstanding
records which the VA has not attempted to obtain.  Accordingly,
no further assistance to the veteran is required to comply with
the duty to assist him as mandated by 38 U.S.C.A. § 5107(a) (West
1991).

II.  Increased Evaluation

Disability ratings are based, as far as practicable, on the
average impairment of earning capacity resulting from disability.
38 U.S.C.A. § 1155 (West 1991).  The average impairment as set
forth in the VA's Schedule for Rating Disabilities, codified in
38 C.F.R. Part 4, includes diagnostic codes which represent
particular disabilities.  Generally, the degrees of disabilities
specified are considered adequate to compensate for a
considerable loss of working time from exacerbation or illness
proportionate to the severity of the several grades of
disability.  38 C.F.R. § 4.1 (1994).  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 of 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 seriously disabled.  38 C.F.R. § 4.40 (1994).

38 C.F.R. § 4.71, Plate II shows that the normal range of motion
of the knees is from 0 degrees' extension to 140 degrees'
flexion.  38 C.F.R. § 4.20 provides that when an unlisted
condition is encountered it will be 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. § 4.7 provides that 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.

Laceration of the right knee with chondromalacia patella is not a
disability listed in the Schedule for Rating Disabilities;
however, 38 C.F.R. § 4.71a contains various Diagnostic Codes that
are pertinent to knee impairment.  In the following paragraphs,
the specific codes that are closely analogous to the veteran's
disability will be addressed.  The provisions of 38 C.F.R.
Part 4, Diagnostic Code 5257 for impairment of the knee with
recurrent subluxation or lateral instability provides a
10 percent evaluation for slight knee impairment.  For moderate
impairment, a 20 percent evaluation is warranted.  The provisions
of 38 C.F.R. Part 4, Diagnostic Code 5260 provide a 10 percent
evaluation for limitation of flexion of the leg to 45 degrees.
For flexion limited to 30 degrees, a 20 percent evaluation is
warranted.  The provisions of 38 C.F.R. Part 4, Diagnostic
Code 5261 provide a 10 percent evaluation for extension of the
leg limited to 10 degrees.  For extension limited to 15 degrees,
a 20 percent evaluation is warranted.

An historical review of the record shows that an original rating
determination in April 1986 established service connection for
laceration of the right knee with chondromalacia patella
evaluated at 10 percent by analogy under 38 C.F.R. Part 4,
Diagnostic Code 5257 based upon incurrence in service as well as
objective findings recorded on a post-service VA orthopedic
examination in February 1986.  At the time of the examination,
the veteran complained of pain in the right knee with a grating
feeling.  The pain occurred about one-half of the time and
especially when he stood or put pressure on it such as walking up
and down the stairs.  It did not lock but had given out on him.
He noted as history that he was hurt in a motor vehicle accident
during active duty.  He was in the hospital for four days as an
inpatient at which time his knee was lacerated and stitched.
There was no fracture at the time and no cast was applied.  From
that time until he left the service, he saw a physician on
multiple occasions.  He was told that he had chondromalacia of
the patella and advised to take aspirin.  No operations were
advised.  Since leaving active duty, he had not seen a physician.
He worked as a self-employed automobile mechanic.  His
medications were occasional aspirin.

Evidence received supporting the veteran's current reopened claim
includes numerous private medical records from the Duluth Clinic,
reflecting ongoing treatment for right knee complaints between
approximately July 1990 and July 1992.  Specifically, when he was
initially seen in July 1990 regarding worker's compensation
injury it was noted that he had a medial plica syndrome with some
patellofemoral pain, conservative treatment with knee
immobilizer, ultrasound to the plica, straight leg raises and
possible "E. Stim" as well.  When he was seen in followup in
August 1990, it was noted that he had an exacerbation of pain
with exercises and ultrasound.  Electric stimulation seemed to
help.  The knee immobilizer reportedly aggravated his symptoms.
He had no swelling or locking complaints.  Objectively, there was
no effusion.  Mild medial joint line tenderness was present.  The
plica was much less palpable than it was previously.  The
tenderness had decreased.  Mild patellofemoral pain was present.
Apley's grind and McMurray's/Lachman's tests were negative.
Impression was patellofemoral pain--slightly improved; medial
plica syndrome--some improved; and questionable medial meniscal
tear.  He was to be rechecked in three weeks and if the pain
persistently was symptomatic the veteran was to be considered for
arthroscopy.

Followup treatment records through early July 1991 continued to
reflect ongoing treatment for right knee symptoms.  At that time
it was noted that the veteran had had chronic right knee pain
since injury in service.  It was noted that veteran's knee
symptoms responded to Indocin, which was not taken on a regular
basis.  It was felt that he might have a patellofemoral pain
syndrome.  The opinion was that he might have a fibrous plica;
however, an evaluation at that time did not demonstrate
significant tenderness over the plica area.  Examination was
described as relatively normal.  The veteran was started on a
strengthening program.  It consisted of terminal knee extension
as well as straight leg quad sets.  He was unable to tolerate the
exercise because of increased symptoms even with 5 pounds.  It
was noted that multiple knee X-rays were all normal without any
evidence of degenerative joint disease.

It was also noted that the veteran worked for the Post Office and
stated that he had a hard time doing his job.  He was unable to
stand because of knee pain.  The examiner got the impression in
July 1991 that the veteran was not very interested in doing his
job and was very interested in being declared disabled.  On
physical examination, the veteran had a normal gait.  He had no
redness or swelling in the knee.  No palpable effusion was
present.  There was no muscle atrophy of his quadriceps.  Full
range of motion of his knee was noted.  There was no vascular
abnormality.  He was pain-free on palpation along the medial and
lateral joint line.  He had no pain with patellar apprehension
either medially or laterally.  Distraction of the quadriceps
tendon and patellar tendon was completely normal.  He had a
negative valgus and varus stress testing, negative Lachman's and
negative McMurray's signs.  He could do a deep knee bend for the
examiner without significant effort or trouble.  He did have a
palpable medial plica on the right but there was also one on the
left.  A long scar over the anterior knee was noted.  The
examiner was in agreement that the veteran had a patellofemoral
pain syndrome; however, he found the veteran to have a relatively
normal examination.  On the basis of the normal examination the
examiner could not explain the degree of symptoms that the
veteran was having.  He noted that if the veteran had significant
quadriceps insufficiency or chondromalacia patella that walking
on even ground and having to absorb the various ground reaction
forces would cause more difficulty to his knee than sitting or
standing on a hard surface, though the compressive loads of
concrete were greater.  He recommended weight loss and closed
chain strengthening program.

Followup physical medicine and rehabilitation medical records
show that in early September 1991 the veteran indicated that he
was doing better.  He noted that he was doing some closed chain
strengthening, riding on a stationary bicycle, doing some squats
and some leg strengthening.  The examiner indicated that he had
spoken to the veteran's physical therapist who noted that he
could not find much wrong with the veteran on initial assessment
or midway through.  While the veteran complained of pain he was
noted to be able to tolerate all the exercises without much
difficulty.  On examination at that time the veteran was noted to
squat without any effort.  He had a fluent gait.  Full range of
motion of his knee was demonstrated with no effusion or swelling.
There was diffuse tenderness at various sites including the
medial plica, Gerdy's tubercle; however, ligaments were intact.
McMurray's sign was negative.  Negative apprehension sign was
noted.  An examination of the knee was described as essentially
normal.  The examiner's impression indicated that he was
uncertain as to the persistence of the veteran's pain.  It was
noted that the veteran appeared focused on disability and was
told that he had minimal disability because of the full motion
and normal ligamentous status and that his primary symptom was
that of pain with very minimal objective findings.  The examiner
indicated that he could imagine it possible that the veteran had
chondromalacia patella, but it would have to be proven through
arthroscopic examination.  It was also indicated that the veteran
had possibly had a minor internal derangement given the
complaints of pain with popping occasionally causing excruciating
pain.  He noted that as of September 1991, the veteran had had a
very aggressive conditioning program although the veteran failed
to respond.  He doubted that more therapy would make a
difference.

When the veteran was seen in December 1991, he noted that he was
doing "okay" as long as he stayed on light duty at work.  He
reported that the preceeding four days were a little worse than
previously and he noted that on one day he had some swelling of
the knee which had since resolved.  On objective examination full
range of motion of the knee was demonstrated.  The medial and
lateral joint lines were minimally tender.  There was no effusion
apparent.  Ligaments were intact.  There was no meniscal click.
He had a medial plica which was nontender to palpation.  The
examination was otherwise benign.  The impression was chronic
knee pain.

In January 1992 it was noted that the veteran complained of
ongoing pain over the anterior aspect of the right knee in spite
of the physical therapy program.  His pain had worsened with
activity, particularly kneeling and prolonged standing.  He noted
occasional swelling localized over the anterior aspect of the
knee at the end of the work day.  He had not had "catching" or
"locking."  An examination showed that the veteran was able to
walk with a normal gait.  Right knee was without effusion.  Full
range of motion was demonstrated.  He was able to squat fully.
Strength about the right knee was satisfactory.  The knee was
stable.  The patella was stable and appeared to track
satisfactorily.  His prepatellar scar remained well healed.
Tenderness about the patella as well as over the lateral joint
line was noted.  Regular McMurray's was noted.  In February 1992,
weight loss to alleviate knee symptoms was recommended.  The
examiner's opinion was that the veteran would have significant
improvement if he were to follow through with a weight loss
program.

Followup private medical records show that when the veteran was
seen in April 1992 he complained of right knee pain and stated
that he had just been turned down for disability retirement
pending a second review of his condition.  It was noted that a
magnetic resonance imaging scan report previously undertaken had
showed minimal narrowing and irregularity of the lateral femoral
component of the patellofemoral joint and some small patellar
osteophytes.  The veteran asked if his pain was "real" and he was
told that his pain was primarily soft tissue.  The pain was
affirmed by the examiner as real but that management of the pain
was a difficult problem.  In July 1992 he was referred for a
functional capacity evaluation.

A report of a standard Polinsky Functional Capacities Assessment
(FCA) dated in August 1992 shows that the veteran's strength and
range of motion were within normal limits throughout.  He had
difficulty performing knee squats due to right knee pain.  He had
difficulty of the right knee when crawling due to increased pain.
Mild edema was noted in the right knee just inferior/lateral to
the patella.  He demonstrated minimal pain behavior during all
activities.  He rarely showed any nonverbal expression with the
exception of sitting and rubbing his knee at rest periods.  He
did not verbalize pain complaints unless requested.  He worked at
a moderate pace overall.  He did work at a slower pace during
balance activities and at a rapid pace during repeated reciprocal
leg motion (biking), repeated bending, and stair climbing
activities.  He demonstrated good overall endurance with smooth,
efficient movements.

It was also noted that the veteran adequately performed the
following activities:  Unloaded repeated bending, biking,
walking, sitting, stair and ladder climbing and balance.  He
complained of right knee pain during sitting and stair/ladder
climbing.  He was functionally limited for kneeling, and unloaded
repeated squatting activities due to right knee pain.  He had
most difficulty with activities requiring right knee and static
position and repetitive right knee flexion.  His performance on
the first day was consistent with performance on the second day
of testing.  It was noted that he was less than average or low
when compared to the normal population on repeated squatting,
kneeling and standing.  He was an average performer on biking,
walking, sitting, stair and ladder climbing, and "reps/min" on
unloaded repeated squatting.  Overall, it was recommended that he
continue with home exercises consisting of walking.  It was also
noted that although the veteran had physical therapy in the past
primarily for strengthening, he might benefit from further
physical therapy.  It was noted that he should return to work
within the guidelines of the Functional Capacities Assessment.

In December 1992, the veteran attended a hearing before a hearing
officer at the RO.  He complained of right knee pain which
increased on activity.  He also noted that while there was no
locking that he experienced some weakness.  He also noted that he
often had swelling of the right knee at the end of the day.
Hearing transcript (T.) at 2, 3.  He also noted from all the
tests he had had that range of motion of the right knee appeared
to be fine.  T. at 2.  He indicated that his main problem was
pain and that sometimes about the end of every week, sometimes
even at the end of one day he experienced pain.  His doctor had
given him Naprosyn, two times a day, 500 milligrams, to ease the
pain.  T. at 5, 6.  He noted that he was on limited duty at work
in accordance with the FCA results.  T. at 4.

On a report of a VA examination dated in December 1992, it was
noted that the veteran reported as history that following a
service accident in which he incurred a large laceration of the
right knee which was sutured and later healed, he generally had
pain in the knee with some numbness and occasional swelling
particularly after long marches or any accidental twist.  He
noted that he had gotten along "quite well" until July 1990 when,
in the course of his job, he was kneeling on a floor and
developed severe pain under his kneecap.  He had had considerable
discomfort going up and down stairs and also some pain on
retiring at night.  There had been no buckling of the knee or
locking.  He noted that he had X-rays and a magnetic resonance
imaging scan done through private facilities and was told that he
had some chondromalacia.  An arthroscopy was not recommended.  He
was given Indocin with good relief but then changed to Naprosyn
which made him uncomfortable.  On objective examination, the
right knee showed slight limitation of flexion to 125 degrees.
The right knee measured 16 1/2 inches while the left knee
measured 16 inches.  There was a well-healed, S-shaped scar over
the patella measuring 4 1/2 inches which was well healed,
nontender and with no discoloration.  No crepitation of the knee
joint was evidenced.  The knee joint was described as entirely
stable.  An X-ray of the right knee was normal.  The diagnoses
were well-healed laceration of the right prepatellar area and
question of chondromalacia, right knee.

A comprehensive analysis of the evidence demonstrates that the
veteran has acute exacerbations and chronic pain of the right
knee.  Specifically, both the private and VA medical evidence of
record shows that between July 1990 and December 1992 aside from
complaints of knee pain, objective examinations have essentially
reflected normal findings.  Private examiners have commented on
the lack of adequate pathology to support the severity of the
veteran's complaints of knee pain when compared to the minimal
objective findings.  Over the recent years the veteran has
generally demonstrated full range of motion of the right knee
with no instability, locking or significant swelling or redness
evidenced.  Additionally, pain behavior was noted to be minimal
on the FCA evaluation.  As for objective findings, on the VA
examination in December 1992, the examiner described slight
limitation of flexion.  The veteran at that time indicated that
he had good relief from pain with certain medication.  For
significant improvement of pain, a private examiner recommended
weight loss.  Accordingly, based on this disability picture,
which shows, at most limitation of right knee flexion to 125
degrees, it cannot be concluded that a rating higher than 10
percent under Diagnostic Codes 5260 or 5261 is warranted.  An
evaluation greater than 10 percent under Diagnostic Code 5257 is
also not in order - despite complaints of chronic pain, objective
findings are minimal, at most.  Consequently, more than resulting
slight impairment is not demonstrated.

III.  Other Considerations

Additionally, the Board points out that consideration has been
given to the application of the various provisions of 38 C.F.R.
Parts 3 and 4, whether or not they were raised by the appellant.
The evidence discussed herein does not show that the service-
connected disorder at issue meets or more nearly approximates the
degree of impairment required for the next higher rating and
therefore the lower rating is retained.  38 C.F.R. § 4.7.
Moreover, the evidence discussed herein does not show the
service-connected disorder at issue presents such an unusual or
exceptional disability picture as to render impractical the
application of the regular schedular standards.  There are no
factors such as frequent hospitalization or marked interference
with employment that would indicate that an increased rating on
an extraschedular basis is in order.  Therefore, the assignment
of an extraschedular evaluation under 38 C.F.R. § 3.321(b) (1994)
is not warranted.

ORDER

An increased evaluation for a laceration of the right knee with
chondromalacia patella is denied.

          M. SABULSKY
          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.