Citation Nr: 0001354 Decision Date: 01/14/00 Archive Date: 01/27/00 DOCKET NO. 96-10 018 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a chronic low back disorder. 2. Entitlement to service connection for residuals of a left femur fracture. 3. Entitlement to an increased evaluation for left knee strain, currently evaluated as 10 percent disabling. 4. Entitlement to a rating in excess of 10 percent for arthritis of the left knee. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The veteran had active service from August 1974 to August 1978. This case was previously before the Board of Veterans' Appeals (Board) in November 1997 at which time it was remanded to the RO for further development with regard to the issues listed on the title page. Of record is a July 1998 rating decision in which service connection for a left hip disorder was denied. The appellant was notified by communication dated that month. She has not submitted a notice of disagreement with the rating decision. Also of record is a December 1998 rating decision in which, among other things, service connection for endometriosis was denied. Additionally, it was indicated that the veteran had not submitted new and material evidence sufficient to reopen a claim of service connection for urethral stenosis. The appellant was informed of the determination by communication dated in January 1999. A notice of disagreement with regard to these issues is not of record. The record reveals that, during the pendency of the appeal, by rating decision dated in December 1998 a separate 10 percent evaluation was assigned, effective July 1, 1997, for degenerative changes of the left knee. The 10 percent evaluation in effect for left knee strain was confirmed and continued. FINDINGS OF FACT 1. The veteran's low back disorder is reasonably associated with his period of active service. 2. There is no competent evidence of the presence of any current disability involving the left femur. 3. Recent examination showed motion of the left knee from zero to 135 degrees with discomfort but without other measurable functional impairment. 4. Recent examination showed only slight medial collateral ligament laxity and no evidence of weakened movement, excess fatigability, or incoordination. CONCLUSIONS OF LAW 1. The veteran has a chronic low back disability which was incurred during her active service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.310 (1999). 2. The claim for service connection for residuals of a left femur fracture is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The criteria for an evaluation in excess of 10 percent for left knee strain have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (1999). 4. The criteria for an evaluation in excess of 10 percent for arthritis of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003- 5260, 5261 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection for a Low Back Disorder As a preliminary matter, the Board finds that the claim for service connection is plausible and capable of substantiation, and thus well grounded within the meaning of 38 U.S.C.A. § 5107(a). When the veteran submits a well- grounded claim, VA must assist him in developing facts pertinent to that claim. 38 U.S.C.A. § 5107(a). The Board is satisfied that all relevant evidence has been obtained regarding the claim and that no further assistance to the veteran is required in order to comply with the provisions of 38 U.S.C.A. § 5107(a). Service connection may be established for disability resulting from a personal injury suffered or a disease contracted in the line of duty or for aggravation of a preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.306. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection, the evidence must demonstrate the existence of a current disability and a causal relationship between that disability and military service. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. 38 U.S.C.A. § 5107(b). If so, the claim is denied; if the evidence is in support of the claim or is in relative equipoise, the claim is allowed. If, after careful review of all the evidence, a reasonable doubt arises regarding service connection, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 3.102. Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a) (1999). Under the provisions of 38 C.F.R. § 3.303(b), with chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease entity is established, there is no requirement of an evidentiary showing of continuity. Continuity of symptomatology is required only when the condition noted during service (or within the presumptive period) is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support the claim. The chronicity provision of § 3.303(b) is applicable where evidence, regardless of its date, shows that the veteran had a chronic condition in service or during an applicable presumptive period and still has such condition. Such evidence must be medical or else related to a condition as to which, under the Court's case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded or reopened on the basis of § 3.303(b) if the condition is observed during service or during any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). Factual Background A review of the service medical records reflects that, on one occasion in January 1975, the appellant complained of low back pain for the past week. Notation was made of a history of an upper respiratory infection. Examination findings included tenderness to the low back. The remainder of the service medical records are without reference to back problems. At the time of the separation examination in August 1978, she did not indicate whether or not she had had or was having recurrent back pain. It was indicated her present health was "good." The post service medical evidence includes the report of a lumbar spine X-ray study done in September 1982. It was interpreted as being normal. There was no evidence of trauma. In a statement dated later that month, a private physician indicated that the appellant had begun having difficulty with the back several years previously. It was reported that, without any history of any injury or any unusual activities, she began to experience intermittent episodes of low back pain. The pain did not radiate, and was not associated with any numbness or tingling and was not worse when she coughed or sneezed. She stated that the episodes had been gradually increasing in frequency and severity over the past several years, and she claimed her back now frequently went out, causing her difficulty with pain that would last several days. Reference was also made to left knee problems. On the basis of clinical examination, the examiner gave a pertinent diagnosis of chronic low back strain. Examination by VA that same month resulted in an indication of full motion of the back. A diagnosis with regard to the back was not made. Of record are reports of periodic visits to a service department medical facility for various problems beginning in the early 1980's. In July 1981, she was seen for a complaint of low back pain. The impression was lumbar strain. At the time of one such visit in November 1983, the veteran complained of back problems. At that time she was given a diagnosis of spinal ligamentous strain. Additional records include the report of an X-ray study of the lumbosacral spine done at a service medical facility in December 1987. When compared to a previous study done in 1986, it was indicated no interval change was apparent. There remained a minimal straightening of the normal lordotic curvature and mild degenerative hypertrophic changes of the lumbar vertebral bodies with disc spaces appearing to be fairly well maintained with minimal flattening of the normal lumbosacral junction disc angle. In an August 1988 communication, the head of the Acute Care Department at the Naval Hospital, Pensacola, Florida, stated that the appellant had been seen in that department from December 1985 to the present for complaints which included chronic low back pain. A CAT scan done in 1988 reportedly showed herniated discs at the L4 and L5 levels. The appellant was accorded an orthopedic examination by VA for rating purposes in January 1995. The claims file was reviewed and history was taken. Reference was made to the aforementioned communication in which the service department physician referred to chronic low back pain. The current examiner commented that no history of injury of the back was noted. Further review of the record indicated that the appellant fell and twisted her back in December 1987. This came shortly after a fall which resulted in a medial meniscectomy of the knee. Reference was made to a note dated March 12, 1985, indicating that she had had a new onset of low back pain which began and which became accentuated after she was wearing a straight leg knee brace for trauma to the left knee. She denied any history of acute injury to the back. Further, it was noted that she gave a history of having received manipulation of the back while in service secondary to pain. Further review of the records indicated that, in February 1985, she had a history of a left knee injury. She fell and sustained a blow of the left kneecap and was treated in a knee immobilizer. There was mention in the records of a right upper back injury secondary to a lifting type of injury in September 1985. According to her history, she injured the left knee in 1978 when she stood up after drawing blood from a patient. From her history and a review of the records, the examiner was unable to obtain a history of injury to the low back while she was in service, although the examiner noted the appellant did indicate that she received treatment for back problems while in service. "Under these conditions, I will be unable to say that her problems with her back began secondary to her service-connected left knee, but rather she indeed had back problems while in the service." The appellant was accorded an examination of her joints by VA for rating purposes in June 1998. The claims file was available for review and reviewed by the examiner prior to the examination. The examiner indicated that the service medical records contained a notation that the appellant was seen in January 1975 for low back pain, but there was no further mention in the service medical records regarding the back. Further review of the records referred to the aforementioned notation of spinal ligamentous strain following a medical visit in November 1983. The examiner also referred to a December 1987 report of the appellant's having injured her low back secondary to a fall at a department store. Current examination resulted in a pertinent impression of degenerative disc disease of the lumbar spine. In responding to the question as to the current nature and etiology of her back difficulties, the examiner stated "the current nature of her back symptomatology is due to degenerative disc disease. The etiology is related to the aging process. As previously indicated, certainly her back will be symptomatic when she sustains a fall secondary to the left knee condition." Also of record is a December 1998 statement from Dr. Edwin Roberts. He indicated that he had been treating the appellant since March 1994. It was his "medical opinion that her [the appellant's] current degenerative disc condition had its earliest manifestation during military service. Her low back condition is not a result of any particular action, but a medical condition developing over years." Elaboration by the physician was not provided. Also of record is a December 1998 communication from an individual who reported having known the appellant since 1977. He stated that he worked with her in 1977 and in 1978 and again from 1982 until the present. He claimed that he had observed her to have both back and knee pain. Also of record is a December 1998 communication from another individual who stated that, while in the Navy with the appellant, she remembered the appellant often complaining of back pain, and she remembered the veteran going to the medicine clinic several times for back problems. Of record is a communication from a third individual who reported having known the appellant since 1977 and having worked with her since 1982. She indicated that she had witnessed the appellant's suffering with back and knee pain. Also of record is a December 1998 communication from Gordon Kellogg, M.D. He stated that he had known the appellant on a medical basis since 1975. He indicated that he was stationed with her at a service department hospital in Spain. He remembered that she was seen for back problems and was aware that she had injured her knee in service and had had a series of falls since the injury which had resulted in an increase in the problems with her left knee and lower back. He believed there were existing records indicating the problems existed prior to her fall in the department store in 1987. He noted that, as a medical technologist, she had been required to perform a number of duties, which involved prolonged standing, bending, and lifting. The physician believed that the appellant's low back problems and degenerative disc condition had their earliest onset in military service. He believed the problems were not due to any specific event, but "due to a long-term medical condition developing over the years." He believed the numerous falls she had had caused her chronic pain in the left knee and lower back and other areas. He believed she would not have had as many falls if her left knee had been stable to begin with. Analysis From a review of the foregoing, it appears that there are differing opinions regarding the etiology of the veteran's low back disorder. However, most physicians have expressed the opinion that it is at least as likely as not that the veteran's current back difficulties are associated with her active service on either a direct basis or as secondary to her service-connected left knee disability. These opinions are sufficient in the opinion of the undersigned for service connection to be granted. Colvin v. Derwinski, 1 Vet. App. 171 (1990). The VA physician who conducted a comprehensive examination on the veteran in June 1998 expressed the opinion that the veteran's degenerative disc disease was related to the aging process. He did not directly rule out service onset, however. Notation was made that the back would become symptomatic whenever she sustained a fall secondary to the left knee disorder. Dr. Roberts, a physician who stated that he had been seeing the appellant since March 1994, expressed an unequivocal opinion that the appellant's degenerative disc condition had its earliest manifestation during her military service. The detailed discussion by Dr. Kellogg, also in December 1998, resulted in the same opinion, with a persuasive discussion opining that the various tasks the appellant had during service and his awareness of back problems she had during service represented the onset of the veteran's back difficulties. He attributed the back disorder not to any specific event, but to an accumulation of stress and strain developing over the years, essentially beginning with the appellant's experiences while on active duty. The undersigned sees no reason to disagree with the persuasive argument by Dr. Kellogg and the evidence of record which shows that the appellant has had continuing problems with her left knee over the years. Essentially, the Board believes that the nature of the veteran's service and the opinions from the physicians put the evidence at least in equipoise. That being the case, the Board resolves reasonable doubt in the veteran's favor, and concludes that service connection for a low back disorder is warranted. Service Connection for Residuals of a Left Femur Fracture The threshold question to be answered is whether the appellant has presented evidence of a well-grounded claim, that is, a claim which is plausible and meritorious on its own or capable of substantiation. If she had not, her appeal must fail, and the Board has no duty to further assist her with the development of her claim. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78 (1990). Case law provides that, although a claim need not be conclusive to be well grounded, it must be accompanied by evidence. A claimant must submit supporting evidence that justifies a belief by a fair and impartial individual that the claim is plausible. Dixon v. Derwinski, 3 Vet. App. 261, 262 (1992). In order for a claim to be well grounded, there must be competent evidence of current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the inservice injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995); see also Epps v. Gober, 126 F.3d 1464 (1997) cert. denied 118 S. Ct. 2348 (1998). The second and third Caluza elements can be satisfied under 38 C.F.R. § 3.303(b) (1999) by (a) evidence that a condition was "noted" during service or during an applicable presumption period; (b) evidence showing post service continuity of symptomatology; and (c) medical, or in certain circumstances, lay evidence of a nexus between the present disability and the post service symptomatology. Clyburn v. West, 12 Vet. App. 296 (1999); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). Alternatively, service connection may be established under § 3.303(b) by evidence of (i) the existence of a chronic disease in service or during an applicable presumption period and (ii) present manifestations of the same chronic disease. Brewer v. West, 11 Vet. App. 228, 231 (1998). A secondary service connection claim is well grounded only if there is medical evidence to connect the asserted secondary condition to the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 10 Vet. App. 432 (1997); see Locher v. Brown, 9 Vet. App. 535, 538-39 (1996) (citing Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995), for the proposition that lay evidence linking a fall to a service-connected weakened leg sufficed on that point as long as there was "medical evidence connecting a currently diagnosed back disability to the fall"); Jones (Wayne) v. Brown, 7 Vet. App. 134, 136-37 (1994) (lay testimony that one condition was caused by a service-connected condition was insufficient to well ground a claim). Where the determinative issue involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Sacks v. West, 11 Vet. App. 314, 315 (1998). Lay assertions of medical causation or diagnosis cannot constitute evidence to render a claim well grounded under 38 U.S.C.A. § 5107(a); if no cognizable evidence is submitted to support a claim, the claim cannot be well grounded. Id. Evidentiary assertions accompanying a claim for VA benefits must be accepted as true for purposes of determining whether the claim is well grounded, unless the evidentiary assertion is inherently incredible or the fact asserted is beyond the competence of the person making the assertion. King v. Derwinski, 5 Vet. App. 19, 21 (1993). A review of the service medical records is without reference to a fracture of the left femur. The post service medical evidence includes the report of a VA examination accorded the veteran in September 1982 at which time no complaints or abnormal findings were made with regard to the left femur. A VA general medical examination accorded the appellant in September 1994 was likewise negative for any reference to a fracture involving the left femur. At the time of a VA orthopedic examination accorded her in January 1995, the appellant reported there was a disagreement between her orthopedist and the radiologist as to whether or not she had a hairline fracture of the left femur secondary to a fall she sustained involving her service-connected left knee in 1985. The examiner commented that "as far as the left femur is concerned, this injury occurred secondary to a fall directly onto the knee while working as a lab technician in 1985, when her knee gave way and therefore, would have to be considered to due to her left knee problem." An X-ray study accorded the appellant by VA in January 1995 showed no evidence of a fracture. Examination of the left knee showed mild degenerative changes. No joint effusions were observed. The impression was mild degenerative changes consistent with the appellant's age, with a notation that otherwise the examination was normal. Of record is a report of magnetic resonance imaging of the left knee done at a private facility in December 1995. There were tearing and fraying of the medial meniscus. The patellofemoral joint was unremarkable and the major ligaments of the knee were intact. There was no reference to a fracture of the femur. Subsequent to the Board's remand, the appellant was accorded an examination of the joints by VA in June 1998. The claims file was available for review. Notation was made that the appellant was claiming a fracture of the left femur secondary to a fall she sustained on the left knee in January 1985. It was reported that during treatment of the injury, X-rays were initially interpreted as being normal, but later on repeat X-rays there was a question of a possible, slight, hairline fracture of the lateral femoral condyle. When asked to respond to an inquiry as to whether there was any evidence reflecting the incurrence of a left femur fracture, the examiner stated that he saw no evidence reflecting any incurrence of a left femur fracture. He reported there was a questionable fracture noted at the time of the injury of the knee and indicated there had been no further indication in the records, including X-ray studies, of the presence of a fracture. Of record are statements made by long-time acquaintances in December 1998. They are without reference to a fracture involving the left femur. The communications from the private physicians dated in December 1998 referred to elsewhere in this decision primarily discuss the veteran's back problems. There was no reference to a disability involving the left femur. Although the appellant is competent to report various problems she might be experiencing, the record does not reflect that she has achieved a recognized degree of medical knowledge that would render her competent to offer opinions as to a medical diagnosis or causation. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The evidence of record does not reflect any medical opinion indicating a relationship between her service-connected left knee disability and a left femur fracture. In fact, the recent examination accorded her by VA failed to document the presence of residuals of a left femur fracture. In this regard, in Brammer v. Derwinski, 3 Vet. App. 223 (1992), the United States Court of Appeals for Veterans Claims (Court) noted that Congress specifically limited entitlement for service-connected injury or disease to cases where disease or injury resulted in disability. In the absence of evidence of current disability, the claim is not plausible. Under such circumstances, the claim with regard to this matter is not well grounded, and must be denied. Entitlement to Increased Ratings for Disabilities Involving the Left Knee Disability evaluations are based on the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). The average impairment as set forth in 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 disability specified are considered adequate to compensate for the loss of working time proportionate to the severity of the several grades of disability. The determination of whether an increased evaluation is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. § 4.1 (1999), which require that each disability be viewed in relation to its history. Although medical reports must be interpreted in light of the whole recorded history, the primary concern in a claim for an increased evaluation for a service-connected disability is the present level of disability. Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The veteran's left knee disability has been evaluated over the years pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5257, which provides a 10 percent evaluation for impairment of the knee with slight recurrent subluxation or lateral instability. A 20 percent rating is assigned when the recurrent subluxation or lateral instability is moderate. The maximum rating of 30 percent is provided when there is recurrent subluxation or lateral instability that is severe. 38 C.F.R. § 4.71a, Code 5257. Degenerative arthritis, established by X-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic code or codes of the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion that is noncompensable under the applicable diagnostic code is assigned a 10 percent evaluation under Code 5003. Id. In the absence of limitation of motion, a 10 percent or 20 percent evaluation is assigned for X-ray evidence of involvement of two or more joints, depending on whether there are occasional incapacitating exacerbations. Id. Under Diagnostic Code 5260, limitation of flexion of either leg to 60 degrees warrants a noncompensable evaluation. A 10 percent evaluation requires that flexion be limited to 45 degrees. A 20 percent evaluation requires that flexion be limited to 30 degrees. Under Diagnostic Code 5261, limitation of extension of the leg to 5 degrees warrants a noncompensable evaluation. A 10 percent rating requires that extension be limited to 10 degrees. A 20 percent evaluation requires that extension be limited to 15 degrees. A 30 percent rating requires that extension be limited to 20 degrees. A 40 percent rating is for assignment when extension is limited to 30 degrees. The maximum rating of 50 percent is provided when extension is limited to 45 degrees. Musculoskeletal disability is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance caused by anatomical damage or infection. The resulting 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 it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Disability in joints, such as the knee, resides in reductions of the normal excursion of movement in different planes. Factors include: Limited or excess movement, weakened movement, excess fatigue, incoordination, and pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. These regulations only apply to diagnostic codes premised on limitation of motion. Diagnostic Code 5257 is not premised on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). A review of the record shows that the veteran's claim has been viewed in light of the opinion of the VA General Counsel regarding separate evaluations when a claimant has arthritis and instability of the knee. VAOPGCPREC 23-97 (1997). In that opinion, the General Counsel held that when a knee disorder is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257, and a veteran also has limitation of knee motion which at least meets the criteria for a zero percent evaluation under 38 C.F.R. § 4.71a, Diagnostic Codes 5260 or 5261, separate evaluations may be assigned for arthritis with limitation of motion and for instability. A separate 10 percent rating can also be assigned under the provisions of Diagnostic Code 5003, where there is X-ray evidence of arthritis and objective evidence of limitation of motion that is noncompensable under the applicable diagnostic code. VAOPGCPREC 9-98 (1998). A review of the evidence of record discloses service connection for a left knee disability has been in effect since 1982. The disability was classified for rating purposes as residuals of left knee strain. A noncompensable rating was assigned from August 3, 1982. At the time of examination by VA in September 1982, there was no effusion, crepitus or laxity of the knees. There were full extension and normal flexion. However, when she was accorded a general medical examination by VA in September 1994, she reported that the knee was bothering her so much in 1987 that she had arthroscopy and surgery for tearing of the medial and lateral meniscus. Currently, the knee joint was described as unstable and she was described as at risk for developing degenerative joint disease in the knee. The disability was described as preventing her from going up and down stairs. By rating decision dated in November 1994, the disability rating was increased to 10 percent effective June 28, 1994. An X-ray study of the left knee done in conjunction with VA examination in January 1995 showed mild degenerative changes. There was no evidence of fracture. No joint effusions were observed. The impression was mild degenerative changes consistent with the appellant's age, with a notation of an otherwise normal examination. Magnetic resonance imaging of the left knee done in December 1995 showed virtually complete degenerative tearing and fraying of the posterior and midportion of the medial meniscus. There was mild medial narrowing. The patellofemoral joint was unremarkable and the major ligaments of the knee were described as intact. The veteran was accorded an examination of the joints for rating purposes by VA in June 1998. The claims file was reviewed by the examiner. A history of her problems with the left knee was provided. It was indicated that she had a chronic-type pain in the left knee which varied in severity. There was a questionable history of swelling. In general, it was indicated weight bearing would cause increased pain of the knee. She stated she would have giving way of the knee with twisting or turning type movements. On examination, she was described as moving about somewhat slowly with a very slight limp noted. She was able to stand erect. The left knee had zero to 135 degrees' motion with discomfort on motion noted. No swelling was indicated. There was tenderness to palpation of the medial joint line. Lachman's sign was negative. There appeared to be slight medial collateral ligament laxity to stress. She was able to heel and toe walk. She could only perform a partial squat secondary to complaints of back and knee pain. Lower extremity muscle strength was 5/5, bilaterally. Reflexes and sensation were intact in the lower extremities. It was noted that magnetic resonance imaging of the left knee done in December 1995 showed degenerative fraying and tearing of the medial meniscus of the knee. No recent studies of the knee have been obtained. The impression was degenerative changes of the knee-status post arthroscopic meniscectomy times two with residual pain and giving way. There was also a notation that the magnetic resonance imaging scan in December 1995 showed degenerative fraying and tear of the medial meniscus. The examiner commented that, regarding the concerns of §§ 4.40 and 4.45, he saw no evidence of weakened movement, excess fatigability or incoordination on examination of the knee. He did note some discomfort on range of motion testing. He thought pain could further limit the veteran's functional ability during a flare up of knee pain or with increased use such as on prolonged periods of weight bearing, as well as with activities such as attempted squatting, but it was not feasible to attempt to express that in terms of additional limitation of motion since this could not be determined with any degree of medical certainty. The examiner saw no involvement of the muscles and nerves as he indicated this was a degenerative process of the knee with a medial meniscus tear. It was noted the appellant was gainfully employed. It was reported that pain was not visibly manifested with movement of the knee, although the appellant described discomfort on range of motion testing. There was no evidence of any muscle atrophy involving the lower extremity. There was also no indication of disuse. Based upon the aforementioned findings and following a full review of the entire record, the Board finds that the criteria for a rating in excess of 10 percent for left knee strain is not warranted and that the criteria for a rating in excess of 10 percent for arthritis is not warranted. In reaching its decision, the Board has considered the complete history of the disabilities in question as well as the current clinical manifestations and the impact the disabilities may have on the earning capacity of the veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1, 4.2. As noted above, at the time of the June 1998 VA rating examination, the appellant had motion of the knee, actively and passively, from zero to 135 degrees. There was no evidence of weakened movement, excess fatigability or incoordination and pain was not visibly manifested on movement of the knee, although the appellant described discomfort on range of motion testing. In essence, the motion restriction of the knee, with consideration of functional impairment, is not such as would warrant a rating in excess of 10 percent under any pertinent code at this time. With regard to the left knee strain, under Code 5257, there would have to be recurrent subluxation or lateral instability to a moderate degree, in order to warrant a higher rating of 20 percent. At the time of the June 1998 examination, there was no incoordination demonstrated on examination of the knee. Notation was made of medial collateral ligament laxity to stress, but it was described as only slight in degree. Other findings on examination included no evidence of any muscle atrophy and no indication of disuse. Accordingly, there is no basis upon which to grant a higher rating than the 10 percent currently in effect for the left knee strain. ORDER Service connection for a chronic low back disorder is granted. To this extent, the appeal is allowed. Service connection for residuals of a left femur fracture is denied. A rating in excess of 10 percent for left knee strain is denied. A rating in excess of 10 percent for arthritis of the left knee is denied. Mark D. Hindin Member, Board of Veterans' Appeals